What does it mean if I want to go to a doctor who is out of my network? Will the insurance company still pay for this?
Often, patients make the choice to go to
providers not participating in their network. If you choose to do this, it is
critical to make sure that you have
"Out-of-Network" (OON) benefits under your policy. If you do not have OON benefits and you elect to receive care at an OON facility, you may not receive
ANY insurance reimbursement. If you have OON benefits, your claim will be processed using the prevailing UCR rates for the services provided. In addition, the provider may "Balance Bill" you for the difference between what the physician charges and what the insurance company pays.
When you sign up for health insurance - just like when you sign your auto or homeowner's policies- you are entering into a contract with the insurance carrier. Regardless of whom your insurance carrier is or what type of insurance you have, you are subject to the terms of your policy. It is critical for you as the patient to understand the way your policy works so you can maximize your benefits and your coverage under your plan.
Example:
OON Facility Bills Actual Charge$1 ,000.00
UCR Allowable Charge $ 400.00
60% (OON) Insurance Paid $ 240.00
Your 40% co-insurance $ 160.00
Balance Billing Choosing OON $ 600.00
Your Total Costs $ 760.00
Even if your policy has an out-of-pocket maximum, it is important to understand that ONLY your portion of the UCR amount allowed is applied towards your
maximum. In the example above, only $160.00 (your portion of the amount the insurance company deemed payable) of the $760.00 you paid is counted toward
your yearly out-of-pocket maximum. For this reason, many patients have much larger than anticipated medical bills when seeking services at an OON provider.
PAF has written a very quick read on this topic accessible at the following link:http://www.patientadvocate.org/requests/publications/GU-Understanding-Insurance-Plan.pdf
If you do not have in-network providers or facilities that are necessary to address your health condition, your referring physician should contact the insurer for an exception to seeking an out-of-network provider. This may require an appeal if a verbal request is not accepted. Evidence supporting the request will be necessary to reverse the insurers decision. In certain circumstances the insurer will pay an in-network rate however you will still be subject to the UCR amount and will have a larger out-of-pocket expense. Talk to the OON provider/facility and learn if they are willing to accept charges as full or work out a payment plan with you if it remains a concern.
PAF suggest that if you enjoy the flexibility of going to those you deem best for your illness and your current plan is limiting to seek other insurance options. It is possible you have more then on option at work for example. You should consider enrolling into the most appropriate plan that fits your medical needs during your open enrollment period (of if you have a qualifying event such a birth, divorce, marriage or loss of employment (spouse or self).
PAF cannot express the importance of understanding the current plan you carry to avoid unnecessary denial of claim and/or financial hardship due to large medical bills.
"Out-of-Network" (OON) benefits under your policy. If you do not have OON benefits and you elect to receive care at an OON facility, you may not receive
ANY insurance reimbursement. If you have OON benefits, your claim will be processed using the prevailing UCR rates for the services provided. In addition, the provider may "Balance Bill" you for the difference between what the physician charges and what the insurance company pays.
When you sign up for health insurance - just like when you sign your auto or homeowner's policies- you are entering into a contract with the insurance carrier. Regardless of whom your insurance carrier is or what type of insurance you have, you are subject to the terms of your policy. It is critical for you as the patient to understand the way your policy works so you can maximize your benefits and your coverage under your plan.
Example:
OON Facility Bills Actual Charge$1 ,000.00
UCR Allowable Charge $ 400.00
60% (OON) Insurance Paid $ 240.00
Your 40% co-insurance $ 160.00
Balance Billing Choosing OON $ 600.00
Your Total Costs $ 760.00
Even if your policy has an out-of-pocket maximum, it is important to understand that ONLY your portion of the UCR amount allowed is applied towards your
maximum. In the example above, only $160.00 (your portion of the amount the insurance company deemed payable) of the $760.00 you paid is counted toward
your yearly out-of-pocket maximum. For this reason, many patients have much larger than anticipated medical bills when seeking services at an OON provider.
PAF has written a very quick read on this topic accessible at the following link:http://www.patientadvocate.org/requests/publications/GU-Understanding-Insurance-Plan.pdf
If you do not have in-network providers or facilities that are necessary to address your health condition, your referring physician should contact the insurer for an exception to seeking an out-of-network provider. This may require an appeal if a verbal request is not accepted. Evidence supporting the request will be necessary to reverse the insurers decision. In certain circumstances the insurer will pay an in-network rate however you will still be subject to the UCR amount and will have a larger out-of-pocket expense. Talk to the OON provider/facility and learn if they are willing to accept charges as full or work out a payment plan with you if it remains a concern.
PAF suggest that if you enjoy the flexibility of going to those you deem best for your illness and your current plan is limiting to seek other insurance options. It is possible you have more then on option at work for example. You should consider enrolling into the most appropriate plan that fits your medical needs during your open enrollment period (of if you have a qualifying event such a birth, divorce, marriage or loss of employment (spouse or self).
PAF cannot express the importance of understanding the current plan you carry to avoid unnecessary denial of claim and/or financial hardship due to large medical bills.
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