Hailey Tran
When it comes to healthcare, choosing a hospital or doctor that is in your insurance network can save you money. Most health plans provide access to a network of doctors, facilities, and pharmacies that have agreed to accept a discounted rate for covered services. However, not all hospitals or doctors are in-network for all insurance plans, and patients may unknowingly receive care from an out-of-network provider, resulting in surprise medical bills. This can happen even at in-network hospitals, as not all providers working there may be in-network. While there are some federal and state protections against balance billing, it is important for patients to understand their insurance plan's network and try to avoid out-of-network care to minimize unexpected costs.
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What You'll Learn
In-network hospitals may have out-of-network doctors
When choosing a health plan, it is important to understand the differences between the networks of doctors and facilities available to you. Most health plans provide access to a network of doctors, facilities, and pharmacies, which are considered in-network. These doctors and facilities must meet certain credentialing requirements and agree to accept a discounted rate for covered services under the health plan. If a doctor or facility has no contract with your health plan, they are considered out-of-network and can charge you full price, which is usually much higher than the in-network discounted rate.
Even if you choose an in-network hospital, that doesn't mean that all the providers working there are also in-network. There may be several providers involved in your treatment, such as surgeons, anesthesiologists, and specialists, who may contract separately with insurers. As a result, you may receive a bill from out-of-network providers even though you were treated at an in-network hospital. This is known as "surprise billing" or "balance billing," where patients are charged the difference between the provider's fee and the plan's payment.
To avoid surprise billing, it is recommended that you ask the hospital to ensure that any doctors assigned to your case are in your plan's network. You should also talk to your doctor and insurer before scheduling a procedure to find out if all the providers involved in your care participate in your plan. Additionally, you can try negotiating with your insurer or provider if you have already received a bill, although they are not obligated to accept a lower rate.
Surprise billing occurs because of the fragmented nature of the US healthcare system, where different kinds of physicians and providers make their own decisions about which insurance networks to join. This can result in higher costs for patients and insurers, as out-of-network providers can charge significantly higher rates. To protect consumers, about a dozen states have enacted laws or protections against surprise billing, and it is recommended that patients review their bills carefully and reach out to their insurers or providers with any questions or concerns.
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Out-of-network care is often more expensive
In-network doctors and facilities have agreed not to charge you more than the agreed-upon cost. However, your share of the costs is different and usually higher for out-of-network care. While there are no copays when you use an out-of-network doctor or facility, you are responsible for paying the coinsurance, or a percentage of covered charges. This may be much higher than the in-network copay or coinsurance amount.
Out-of-network costs can add up quickly, even for routine care. If you have a serious illness or injury, it can mean paying thousands of dollars more. For example, a couple who had good health insurance coverage received a surprise medical bill of $32,325 after surgery. They had gone to an in-network hospital, but the doctor who treated them was out-of-network. Their insurance company sent them a check for what it deemed a reasonable rate for the procedure, about $4,000, leaving the couple on the hook for the remaining $28,000.
To avoid unexpected medical bills, it is important to understand the difference between in-network and out-of-network providers and to know how your plan works. Most health plans provide access to a network of doctors, facilities, and pharmacies that have agreed to accept a discounted rate for covered services. These health care providers are considered in-network. If a doctor or facility has no contract with your health plan, they are considered out-of-network and can charge you full price.
If you need surgery or have a serious illness, there may be several providers involved in your treatment, and each of them may contract separately with insurers. When you receive treatment in a hospital, be aware that you may get a bill from providers who don't participate in your network. Your plan may not cover any out-of-network care, leaving you to pay the full cost. Or, they may cover part of the cost, but at a much lower rate than the provider charges. You may have to pay the difference, receiving a "balance bill" from your provider for the difference between your plan's payment and the provider's fee.
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Emergency care is usually covered, regardless of the network status
In the event of an emergency, it is advised to seek care from the closest hospital that can help. This is because, in a true emergency, insurers cannot require prior approval before receiving emergency services from an out-of-network provider or hospital. Most plans cover emergency care, regardless of whether the hospital is in-network or not. This is also true under the Affordable Care Act (ACA), which covers emergency services as one of the ten essential health benefits that ACA-compliant insurance plans must include.
However, it is important to note that this only applies to "true emergencies", and emergency room visits cost more than regular doctor visits. Insurers may not pay certain emergency costs if the situation is not deemed a genuine emergency. Additionally, while balance billing is prohibited under the ACA, it can still lead to significant out-of-pocket expenses. This occurs when providers are not covered as part of an insurance plan and can result in unexpected out-of-network bills.
To avoid costly bills, it is recommended to familiarize oneself with the insurance network, plan ahead, and check with insurance companies and providers for billing details. It is also important to be aware that, even when receiving treatment at an in-network hospital, one may still receive bills from out-of-network providers involved in the treatment. Therefore, it is advisable to ask the hospital to ensure that any doctors assigned to your case are part of your insurance plan's network.
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Preventative care is usually covered only when in-network
Preventative care services, such as annual check-ups, flu shots, mammograms, and colonoscopies, are often covered by health plans. However, it is important to note that these services are typically only covered at no cost to the patient when provided by an in-network doctor or other healthcare provider. This means that the healthcare provider must have a contract with the patient's health plan and agree to accept a discounted rate for the covered services.
When choosing a health plan, it is essential to understand the network of providers associated with that plan. In-network providers have agreed to accept a discounted rate for covered services, which helps patients save money on their medical expenses. On the other hand, out-of-network providers have no contract with the patient's health plan and can charge full price for their services, which is usually much higher than the in-network rate.
In some cases, patients may unknowingly receive treatment from out-of-network providers, even when they are at an in-network hospital. This can result in surprise medical bills or balance bills, where the patient is responsible for paying the difference between the provider's fee and the amount covered by their health plan. To avoid this, patients should ask the hospital admissions staff to ensure that any doctors assigned to their case are in their plan's network.
Additionally, most health plans cover emergency care, regardless of whether the hospital is in-network or not. However, this usually applies only to true emergencies, and insurers may not cover certain emergency costs if they deem the situation to be non-urgent. Once the patient's condition is stable, they will typically be transferred to an in-network facility for follow-up care.
To summarize, preventative care services are typically covered by health plans but only when provided by in-network doctors or healthcare providers. Patients should be proactive in understanding their health plan's network and communicating with their insurer and healthcare providers to avoid unexpected out-of-pocket expenses.
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Federal and state protections may prevent balance billing
When a patient receives treatment from an out-of-network provider, they may be billed for the difference between the provider's bill and the amount covered by their health insurance. This is known as "balance billing". This can occur when a patient receives emergency care at an out-of-network facility or from an out-of-network provider, or when a patient receives non-emergency care at an in-network facility but is treated by an out-of-network provider.
In the United States, federal and state protections have been implemented to prevent balance billing, with 33 states having enacted laws to protect enrollees from balance billing as of 2020. These protections vary in scope, with only six states—California, Connecticut, Florida, Illinois, Maryland, and New York—offering "comprehensive" protections. New Jersey has also been recognised for its strong dispute-resolution process to establish a payment amount for out-of-network services.
In December 2020, Congress enacted the No Surprises Act, a federal law that protects consumers with private health insurance from out-of-network surprise bills in certain situations. The Act limits the amount paid out of pocket by the patient to what they would have paid if the provider were in-network, using a recognised market amount or qualifying figure (like the average fee for the service). It also outlines a process for insurance companies and providers to settle disputes over charges and requires certain providers to disclose federal and state patient protections against balance billing.
The No Surprises Act applies to those with a group health plan or group or individual health insurance coverage, protecting them from surprise billing for emergency services and out-of-network cost-sharing. It also applies to non-emergency care from out-of-network providers at certain in-network facilities and air ambulance services from out-of-network providers. In such cases, patients will generally only need to pay their normal in-network costs.
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Frequently asked questions
Doctors and facilities that are considered in-network must meet certain credentialing requirements and agree to accept a discounted rate for covered services under a health plan.
If you go to an out-of-network hospital, you may be responsible for paying the full cost of treatment. Plans generally do not cover care received from an out-of-network provider.
You can check if a hospital is in-network by going to your insurance company's website or calling your insurance company directly.
