In-Network vs. Out-of-Network Insurance: What’s the difference?

• June 8, 2016

Insurance is one of those things that almost everyone has but most people don’t fully understand. One of the most mysterious aspects of insurance is why some doctor’s are considered in-network and why others are out-of-network. Once you understand what makes these doctor’s different, you can then evaluate the true cost of your back pain treatment.

In-Network Vs. Out-of-Network Insurance: The Basics

Understanding the differences between in-network and out-of-network charges before you have surgery will allow you to focus on recovering without the worry of surprise charges. Over the years, out-of-network has become a term that fills patients with unease. Out-of-network doctors and medical practices have agreements with insurance companies to provide care for their members at a fixed price. If your doctor does not have an agreement with your insurance company, he is labeled out-of-network. There are many quality doctors that do not contract with insurance companies, because they don’t have to. As a result, many insurance policies provide some out of network benefit. This means that you have the power to choose your physician rather than your insurance company choosing one for you.

What Should I Know When Choosing an Out-of-Network Provider?

If you use an out-of-network provider, be sure to get an estimate of all costs and charges before you have you agree to any treatment. Deductibles, out of pocket maximums, and even co-insurance requirements typically are different for out-of-network services than they are for in-network services. You want to fully understand what your insurance company will cover and what you will be responsible for. Be sure to ask if there are any other factors that you may qualify for such as; charitable deductions or prompt-pay discounts. In some cases, out of network providers that provide these discounts could reduce your costs to the same or even below what the cost of seeing an in-network physician would be, and the decision of which provider won’t be limited.

Are Out of Network Options Worth it?

Recently, many insurance companies have started to limit reimbursement for some out-of-network plans. In many cases, these plans cap what your insurance company is responsible for paying to the amount they would have paid if you went to an in-network provider. These new plans also cost employers more because they are providing what seems like an “out of network” option to their workforce. Given the extra cost of plans with an out of network benefit (at least to the employer), policyholders should closely examine these limited reimbursement plans to see if they are receiving value to justify the extra cost.
Many insurance companies now let the company that is buying the health insurance choose the level of reimbursement these plans will pay. For potential patients, talking to the HR department at your company to let them know if the out of network option is important to you can play a role in ensuring you have a decent out of network benefit.

Why Does it Matter?

The quality of the care you are going to receive should be your top priority when looking into any treatment options. Once you have found a physician that you feel confident will work with you to eliminate your pain, you should then investigate what your insurance network can do to help with the cost. Solving your back pain with as few treatments as possible will prove to be invaluable.