What does it mean to be an out of network provider? The truth
What does it mean to be an out of network provider?
An out-of-network provider is a healthcare provider or facility that is not part of a particular health insurance plan's network. Health insurance companies typically contract with a wide range of doctors, hospitals, clinics, and other healthcare providers to deliver services to their insured members at lower rates. These healthcare providers are known as "in-network" providers.
When a healthcare provider is "out-of-network," it means they have not signed a contract with the health insurance plan to provide services at the negotiated lower rates. As a result, seeing an out-of-network provider can mean higher out-of-pocket costs for the patient, as insurance plans typically cover less of the cost for out-of-network services. In some cases, out-of-network care might not be covered by the insurance plan at all, leaving the patient responsible for the full cost. But this is not always the case… which you will read about below.
It's always important for patients to verify whether a healthcare provider is in-network or out-of-network before receiving services, as this can significantly impact the cost of their care.
What does it mean for me if someone is out of network?
If the provider you are searching for is out of network, you will need to verify with your own insurance plan if the services will be covered. Here are 3 easy steps to do this:
Look on your insurance card. If you see something that says “OON” or “Out of Network”, you’re good to go. How much will it cost? Read below for tips on that.
Call the number on the back. It will lead you to an automated message where you can simply type in your insurance ID, click the # for “Benefits & Eligibility” and it will inform you about your benefits. Listen for Out of Network.
Ask the provider to check the insurance for you. Most will be able to do this for you. For example, we need a copy of your insurance and a date of birth and we can get this information for you.
Why would a provider choose to be out of network? Isn’t that unfair to me?
Often, we view our healthcare from the patient's perspective, and rightly so, as we're the ones seeking care. However, to truly navigate the healthcare landscape, understanding why some healthcare providers choose to remain 'out-of-network' can be just as important.
As patients, we're familiar with the term 'out-of-network', but what does it mean from a provider's perspective? Simply put, an out-of-network provider has chosen not to enter a contractual agreement with a health insurance company. This means they haven't agreed to accept the insurer's pre-negotiated rates for services. Often, these rates are very low. This can lead to higher turnover rates for clinicians, lower availability due to the need to increase the amount of patients one takes on, and burnout. While this may seem like a decision that prioritizes financial gain over patient access, it's essential to recognize the complexities behind this choice.
An even more frustrating insurance problem is, even if a provider is “In-Network” with your insurance, they may not be with “your plan”. What this means is, a provider (doctor) may be “in-network” with an insurance company. However, that contract will only cover certain plans. If your plan is not this plan, your insurance will not cover it. This can be unknown to you and the provider at times. The insurance company can also choose to dictate when they stop covering services for your plan. Leaving you to pay full costs at a certain point.
A major reason providers opt for an out-of-network status is to maintain their autonomy. Being in-network often comes with stringent requirements about how to run their practice, which treatments to provide, and how much time to spend with each patient. For some providers, especially those offering specialized or niche services, these conditions may compromise the quality of care they can deliver. By remaining out-of-network, they can prioritize patient care according to their professional judgment and expertise.
Administrative burden is another significant factor. Dealing with insurance companies often involves time-consuming paperwork and challenging negotiations over service costs and coverage. By stepping away from these administrative tasks, providers can focus more of their time and energy on patient care.
That being said, is it unfair to you, the patient? On the surface, it may seem so, given the potential for higher out-of-pocket costs. But remember, healthcare is more than just a financial transaction. The quality of care, the attention you receive, and the outcomes you achieve are equally, if not more, important. Sometimes, seeing an out-of-network provider might be worth the extra cost, especially for specialized care that aligns more closely with your healthcare needs. However, it may not always lead to more costs for you. Some providers choose not to deal with insurance at all. Here, we still will provide the documentation and billing to insurance for you. So, you only have to worry about the copay costs. Just like any other in-network service you’re seeking.
However, it's crucial to balance your healthcare needs with your financial resources. Before making a decision, research your options, understand your insurance plan's coverage, and don't hesitate to have open conversations about costs with your healthcare provider. After all, informed decision-making is a cornerstone of effective healthcare.
What do I need to do for an Out of Network Provider?
Request a Cost Estimate: Once you understand your coverage, the next step is to ask the out-of-network provider for a cost estimate for your visit and any anticipated treatments. This can help you avoid surprise bills and plan for potential out-of-pocket expenses.
Consider a Prior Authorization: In some cases, you might be able to obtain coverage for out-of-network services by getting a 'prior authorization' or 'pre-authorization' from your insurance company. This is essentially an agreement from your insurer to cover the service. Contact your insurance company to see if this might be an option for you.
Discuss Payment Options: Many out-of-network providers understand the financial constraints patients might face, and some offer flexible payment plans or even sliding-scale fees based on income. Don't hesitate to discuss these possibilities.
Keep Detailed Records: If you're planning to file a claim for reimbursement, ensure you keep detailed records. This includes receipts, invoices, medical records, and any correspondence between you, your provider, and your insurance company.
File a Claim: If your insurance plan covers a portion of out-of-network care, you'll need to file a claim to get reimbursed. The process can vary by insurer, so reach out to your insurance company for specific instructions. Most of the time, you can simply Email or Upload a document the provider sends you on the insurers website. Or, see if the provider will file the claims for you.
Overall, I know this can be confusing, frustrating, and annoying. That’s the American way of dealing with insurance companies. However, it doesn’t always lead to these feelings. At Thriving Minds Therapy, we try to handle everything for you to make it as simple as possible.
If you want us to check your insurance, send us an email!
