The majority of health insurance companies negotiate with specific health care providers and medical facilities, offering to cover the cost of care at a discounted rate. Those who agree to provide services at a discounted rate are referred to as “in-network” doctors or facilities. When you receive treatment that is covered by your insurance plan’s network of coverage, you receive the discounted rate that medical professionals and hospitals agreed on; however, when it comes to health care, staying “in-network” isn’t always possible. A trip to the emergency room, for example, may prevent you from staying within your insurance plan’s network.
When you receive treatment from a health care professional that isn’t covered by your health insurance plan, this is referred to as “out-of-network” care. When that happens, you can end up being charged with a larger percentage, if not all of the costs of the services you received; and those costs can be quite exorbitant. To avoid being hit with unexpected expenses, it’s important to understand what you can do to control the cost of out-of-network care.
Avoid the Cost of Out-of-Network Care
The best way to avoid out-of-network costs is to ensure you receive services from doctors and facilities that are in your plan’s network of coverage. There are several ways that you can do that:
- Familiarize yourself with your coverage. Make sure that you are fully aware of your insurance coverage and what doctors and facilities are within your network. Contact your insurance company or visit their website to receive a full list of what is covered, and stay within your network.
- Speak to your health care provider. Before you receive medical care, find out if the doctor or facility is in your network. Don’t assume that just because they say they will work with your insurer that they are in your network. While they may send your insurance company a bill for the services you received, your carrier may only agree to cover 5 percent of the cost, which means that you will be responsible for the remaining 95 percent.
- Make plans ahead of time. If you need to receive treatment from a doctor or hospital that isn’t in your plan’s network, contact your insurance company ahead of time. There’s a chance that they may be willing to work with you or offer you different options. You may also be able to extend your coverage; however, do be aware that you will likely have to pay more than what you are currently paying for your plan.
Handling Unexpected Bills
Despite your best efforts to stay within your network, it isn’t always possible. For example, if an emergency arises, you may end up receiving treatment at a facility or from a doctor who isn’t in your network; or, the only pharmacy that offers the prescription that you need is out-of-network. Being sick is bad enough; finding out that you are responsible for a costly bill – despite the fact that you have insurance – only makes matters worse.
If you do receive a bill for out-of-network care, there are a few ways that you can attempt to reduce the cost.
- File a complaint. Contact your insurance company and file a complaint. You just may be able to get your carrier to cover at least a portion of the out-of-network care you receive. Be firm and don’t take no for an answer. Make it impossible for your carrier to refuse to cover part of the expense.
- Negotiate. Reach out to the billing department of the doctor or the facility. Be candid; let them know that you are unable to afford the bill and ask if there is any way they can adjust the cost so that it’s more affordable; if they can’t, find out if they can set up a payment plan.
- Work with an advocate. If your attempts to file complaints and make negotiations have failed, or if you are unable to make the effort yourself, consider working with an advocate that specializes in medical billing. These professionals will work to negotiate the cost of your unexpected out-of-network medical bills on your behalf. They will also set up payment plans with the billing department. While you do have to pay for the services of an advocate, you may end up spending less on these services than you would on paying the full cost of out-of-network care.
Summing It Up
Health insurance is ever-changing. Services and providers that are covered now may not be in the future, or you may simply require care that isn’t within your policy’s network of coverage. Fortunately, there are ways that you can try to reduce out-of-network expenses, and with diligence, you will likely be able to successfully lower the cost. If you feel that your policy doesn’t offer the coverage that you need, consider changing it so that you can receive the care that you require from the doctors and medical facilities that are best for your needs.