Logan Reid
Hospitals are considered out-of-network when they have no contract with your health plan and can charge you full price for their services. This is in contrast to in-network hospitals, which are part of a network of doctors, facilities, and pharmacies that have agreed to accept discounted rates for covered services under a health plan. In the case of an emergency, you may not have a choice about where to go for care and will usually be taken to the nearest hospital, which may be out-of-network. While federal and state laws, such as the No Surprises Act, protect patients from surprise billing or balance billing in these situations, it is still important to understand the differences between in-network and out-of-network care to help save on healthcare expenses.
| Characteristics | Values |
|---|---|
| Definition | Out-of-network refers to physicians, hospitals, or healthcare providers who do not participate in a health plan's provider network. |
| Cost | Out-of-network providers can charge full price, which is usually much higher than the in-network discounted rate. |
| Insurance Coverage | Health insurance plans that cover out-of-network care are less common in the individual market than in the employer-sponsored group market. |
| Surprise Billing | The No Surprises Act aims to protect consumers from surprise medical bills, which are unexpected bills from out-of-network providers or facilities. |
| Emergency Services | Federal law protects individuals from out-of-network bills for emergency services in hospitals and independent emergency departments. |
| Balance Billing | Out-of-network providers may engage in balance billing, charging the difference between their bill and the amount covered by insurance. |
| Provider Network | The provider network refers to doctors, facilities, and pharmacies that are part of an individual's health plan and offer discounted rates for covered services. |
| Location | Network availability may vary depending on the plan chosen and the individual's location. |
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What You'll Learn
- Hospitals are out-of-network when they haven't signed a contract with your health plan
- Out-of-network costs are often much higher than in-network costs
- You may be taken to an out-of-network hospital in an emergency
- You can avoid unexpected medical bills by knowing how your plan works
- You can try to negotiate an out-of-network bill, but providers are under no obligation to accept
Hospitals are out-of-network when they haven't signed a contract with your health plan
Hospitals are considered out-of-network when they haven't signed a contract with your health plan. This means that they are not part of the network of doctors, facilities, and pharmacies that your insurance provider has agreed on discounted rates with. As a result, out-of-network hospitals can charge you full price for their services, which can be significantly higher than the rates negotiated by your insurance company for in-network hospitals.
It's important to understand the difference between in-network and out-of-network care to avoid unexpected medical bills. When choosing a health plan, pay attention to the network of providers available to you, as some networks may be larger or include different choices of providers in your local area. You can also check if your preferred hospitals and doctors are in-network before receiving care to ensure you're getting the most coverage from your insurance plan.
In some cases, you may receive care at an in-network hospital but be treated by out-of-network providers, such as radiologists, anesthesiologists, pathologists, or surgeons. These out-of-network providers may bill you for the difference between what your insurance plan covers and their full charges, which is known as "balance billing." To avoid this, you can request that any doctors assigned to your case be in-network and include this request in your hospital records and any forms you sign.
Additionally, it's worth noting that emergency services are often exempt from out-of-network billing. Federal laws, such as the No Surprises Act, protect individuals from surprise billing or balance billing when they receive emergency care at out-of-network facilities or from out-of-network providers at in-network facilities. However, this protection may not extend to post-stabilization services, and you may be required to give up your protections by signing a notice and consent form.
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Out-of-network costs are often much higher than in-network costs
In most cases, you will be protected from unexpected out-of-network bills for post-stabilization services. Federal law protects you from out-of-network bills for emergency services in hospitals, hospital outpatient departments, and independent, freestanding emergency departments. However, if you give written consent, you may give up your protections from balance billing for post-stabilization services.
In some cases, you may be seen by an out-of-network provider while getting care at an in-network facility. For example, your local hospital may be in-network, but an attending physician might be out-of-network. In these cases, the most those providers may bill you is your plan's in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services.
To avoid unexpected medical bills, it is important to know how your plan works. Most health plans provide access to a network of doctors, facilities, and pharmacies that must meet certain credentialing requirements and agree to accept a discounted rate for covered services under the health plan. These health care providers are considered in-network. If you have a Primary Care Physician (PCP), they can help ensure that you are getting the care you need and transfer you to an in-network facility if necessary.
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You may be taken to an out-of-network hospital in an emergency
In an emergency, you may not have a choice about where to go for care. If you are, for instance, in a car accident or suffer a heart attack, you will usually be taken to the nearest hospital, which may not be in your network. Even if the hospital is in your network, some of the ER doctors or consulting specialists who treat you might not be.
Waiting to get care in an emergency can be life-threatening, so most plans cover emergency care regardless of where you are – even if the hospital is out of your network. Once your condition is stable, you will generally be moved to an in-network facility for follow-up care. However, insurers often won't pay certain emergency costs if it is not a genuine emergency.
If you have a Primary Care Physician (PCP), they can ensure you are getting the care you need and transfer you to an in-network facility if necessary. You can also ask your doctor in advance to only use in-network providers, and check with your insurer that they are in your network. If you are purchasing individual and family plan coverage, a PCP may be assigned to you.
In the case that you receive a surprise bill for out-of-network care, you may be protected under the No Surprises Act, which was passed by Congress in 2021. This Act protects patients from surprise bills for emergency services at out-of-network facilities or for out-of-network providers at in-network facilities, only holding them liable for in-network cost-sharing amounts.
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You can avoid unexpected medical bills by knowing how your plan works
Unexpected medical bills can be stressful and financially challenging. Understanding how your health insurance plan works can help you avoid these surprises and manage your healthcare expenses effectively. Here are some ways you can become a more informed patient and sidestep unexpected medical bills:
Know the Difference Between In-Network and Out-of-Network Care:
In-network doctors, facilities, and pharmacies are part of your health plan's network and have agreed to accept a discounted rate for covered services. Using in-network providers helps you save money as you are only responsible for paying a copay or coinsurance amount, which is usually lower than out-of-pocket costs. Out-of-network providers, on the other hand, have no contract with your health plan and can charge you full price, leading to higher expenses.
Understand Your Health Plan's Network:
Different health plans offer varying provider networks. When choosing a plan, consider the size of the network and whether your preferred doctors and facilities are included. Review your plan documents to identify in-network providers and use tools like the Shoppable Services tool to compare prices for services in your area. Knowing your network can help you make informed choices and avoid unexpected bills.
Communicate Your Preferences:
When arranging hospital admission, include a request for doctors assigned to your case to be in your plan's network. Ensure this request is documented in your records and any forms you sign. Communicate your preferences clearly to your doctor, and if they suggest specific providers, verify their network status with your insurer. Taking these proactive steps can help prevent surprise bills.
Be Aware of Emergency Care Considerations:
In emergency situations, such as a car accident or a heart attack, you may not have a choice of hospital. Your health plan typically covers emergency care, even if the hospital is out-of-network. However, some ER doctors or specialists involved in your care might be out-of-network, resulting in unexpected bills. Once your condition stabilizes, you will likely be transferred to an in-network facility for follow-up care.
Understand Your Rights and Protections:
Familiarize yourself with laws like the No Surprises Act, which protects you from certain surprise medical bills. This Act limits your out-of-pocket expenses for emergency services, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services. It also outlines a dispute resolution process between your insurance company and the provider to ensure fair charges. Knowing your rights can empower you to avoid unexpected costs.
By taking the time to understand your health plan, knowing the difference between in-network and out-of-network care, and being proactive in your choices, you can significantly reduce the likelihood of unexpected medical bills and make more informed decisions regarding your healthcare.
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You can try to negotiate an out-of-network bill, but providers are under no obligation to accept
Out-of-network providers can charge patients at higher rates and bill them for the remainder after their insurance company has paid its share. This is called balance billing and can cost patients thousands of dollars.
Since 2022, the federal No Surprises Act has protected consumers from "surprise" balance billing from out-of-network providers. For example, consumers in New York are protected from surprise bills when treated by an out-of-network provider at a participating hospital or ambulatory surgical center included in their health plan's network.
However, the No Surprises Act does not apply to "excepted benefits" or other plans that aren't regulated by the Affordable Care Act. This includes coverage such as short-term health insurance, limited benefit plans, health care sharing ministry plans, and Farm Bureau plans in some states.
While patients can try to negotiate after receiving a bill, out-of-network providers are not obligated to accept a lower payment. Patients can try negotiating with their insurer, which may be able to negotiate with the doctor to accept their rate as full payment or lower the fee.
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Frequently asked questions
"Out of network" refers to physicians, hospitals, or healthcare providers who do not participate in a health plan's provider network.
Hospitals are considered out of network when they have no contract with your health plan and can charge you full price.
You can refer to your plan documents for network details. You can also contact your insurer to confirm if a hospital is in your network.
Yes, you can go to an out-of-network hospital, but you will likely pay more than if you went to an in-network hospital. You may also receive a "surprise" or "balance" bill.
A "surprise" or "balance" bill is when an out-of-network provider bills you for the difference between what your plan covers and the full amount charged for a service.
