In-Network vs Out-of-Network Providers

There are all types of health care providers and you probably have some that you prefer over others.  It’s important to know who is within your Provider Network (also called in-network).  Those are practicing clinicians, pharmacies, and labs associated with your insurance plan. When you receive services in-network they are provided at a discounted rate. While some types of insurance plans will allow you to go out-of-network, you could end up paying a significant amount more - or even full price.  

Here are some examples of when you may need to check to be sure a provider is within network:

1. You just started a new job and now you’re on a new health insurance plan. Your calendar notifies you that you have your annual well-visit or check-up this week. Your primary care provider proactively scheduled it at your last annual visit. Without thinking about it, you go. You’ve been going to the same primary care provider, specialists, and dentist for years. If these providers are not considered in-network with your new health insurance plan, you could get stuck with a larger bill than you planned for. Hopefully, your health care providers ask if you have any insurance changes and alert you if they are now out-of-network. Unfortunately, that may not happen.
2. You have a hospital stay and see an anesthesiologist, a surgeon, and several other providers. Some of them were in-network and some were not.
3. Your health care provider completes blood work and sends it to a lab, but the lab is out-of-network.
4. You have an x-ray completed with an in-network provider, but the radiologist who reads and interprets the results is out-of-network.

In some of these examples, choosing an in-network provider may seem out of your control. Hospital stays and lab work can get dicey. Your best bet is to advocate for yourself as much as possible. If you have a planned visit, check with your health insurance company or the provider to see if they are in-network. Check to make sure that your health care provider is using network providers for any extra services. In the event of a hospital stay or if you are incapacitated, identify a family member to advocate on your behalf. 

Any time you have a health insurance change or are referred to a new provider you should check to make sure they are in your provider network. Most health insurance companies and plans allow you to find this information through your customer portal on their website. You can also go the more traditional route and call your health insurance company OR the health care provider directly.

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Resource:

• healthychildren.org