Out-of-network healthcare providers must still sign contracts agreeing to accept a health insurance plan’s negotiated fees. Most plans pay for out-of-network care based on what they determine are “reasonable and customary” charges in a given geographic area.
The best way to avoid costly out-of-network charges is to stay in-network. However, that’s only sometimes possible.
Get a Quote
Whether you have an individual/family plan, Medicare Advantage, or small group employer-sponsored health insurance, you can go to out-of-network medical providers. However, if you do so, it is essential to understand your insurance coverage and how to get reimbursed for these services with the help of companies like Superbill.
Many people need clarification about what makes a healthcare provider in or out of the network. Insurers maintain network directories that list all of their participating healthcare providers. If a healthcare provider isn’t listed in the directory, they are generally out of network.
To be in-network, a healthcare provider must agree to a negotiated rate with the insurance company for their services. If a healthcare provider typically charges $150 for an office visit but is in-network with your health insurance, the insurer will pay them $90, saving you $60.
If you receive an insurance Explanation of Benefits (EOB) that shows that you have been balanced billed, you should call the customer service number on your health insurance card to resolve the issue. Insurance companies often try to find small reasons to deny out-of-network claims, but it’s important to remain determined.
Request Prior Authorization
For most types of health care services, your insurance company requires prior authorization before they’ll pay for them. Your health provider is responsible for starting the prior authorization process, and they’re often the ones who communicate with your insurer. They’ll explain why they think the service is necessary and why it falls under your coverage.
If your healthcare provider disagrees with your insurance company, they can try to convince them to change their mind. But that’s rare. Health insurance companies are independent organizations with different rules and guidelines, so the people making decisions don’t always speak with one another.
Identifying who handles prior authorizations at your doctor’s office is a good idea, and working with them closely is a good idea. The more they know about the policies and procedures of your insurance company, the more likely it is that your requests will be approved. Some companies publish the clinical guidelines they use to approve or deny medical services and are usually willing to share them with you.
Make the Appointment
Many health insurance providers must be in-network with all types of health plans. This is especially true of therapists, acupuncturists, chiropractors, psychiatrists, and other specialists. Getting a bill from an out-of-network doctor can be a significant financial surprise.
A healthcare provider becomes in-network when it signs a contract with your health insurance company agreeing to be paid at the in-network rate for the services provided. Generally, these contracts are negotiated through a process that includes screening the medical providers to ensure they are licensed and that their facilities meet specific quality standards.
Health insurance companies also have ongoing programs to monitor the quality of the in-network providers. They can drop out-of-network providers from their networks if they don’t meet the health plan’s standards.
Getting your health insurance company to pay for out-of-network care at the in-network rates is possible, but it’s not sure. An excellent place to start is with your in-network primary care physician, who can submit a formal request to the insurance company on your behalf.
File a Claim
You’ll usually get a health insurance claim form (called a CMS-1500, often called a pink sheet because of its color) from your doctor. The doctor’s or hospital billing department will fill out this form and send it to your insurance company. The insurance company will then process the claim and pay your doctor based on the terms of your health plan.
Generally, insurance companies will reimburse you for up to the amount they call the “allowed amount” for a service.
It’s important to note that while out-of-network health care may be more expensive than in-network care, your deductible still applies to all healthcare costs, including out-of-network services. It’s also worth noting that supplemental health insurance plans can help reduce the cost of out-of-network care by covering deductibles and out-of-pocket costs, so you only end up paying what you need to.
As a consumer, you can avoid paying out-of-network rates by researching and looking for providers who are in-network with your health insurance plan. However, there may be times when you have to go out-of-network for medical care, such as during an emergency or after a natural disaster.
In those situations, your insurance provider will usually reimburse you for out-of-network costs at a lower rate than they would in-network. To get an idea of how much your insurance company will pay for out-of-network services, you can check online resources or a site that compares your insurer’s reimbursement rates to Medicare’s fee schedule.
Reviewing your explanation of benefits (EOB) after you receive care is also a good idea. Depending on your plan, you may find that you’re only responsible for up to the deductible or coinsurance amount for out-of-network services.
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