If you’ve recently paid a visit to a new doctor or have been in the market for new health insurance, chances are you’ve heard the terminology of services being either “in” or “out” of network. The following article details what exactly is meant by a service being in or out of network, as well as the benefits of staying in network for health insurance and the disadvantages of going out of network.
A health insurance “network” is the network of doctors and healthcare facilities that your insurance company has a contract with. By utilizing healthcare services that are in your network, you will be receiving services at a discounted rate negotiated by your carrier. If you receive healthcare services that are out of your network, meaning services from doctors or facilities that do not have a contract with your carrier, you will not receive the same benefits and may even need to pay the entirety of the bill. You will benefit the most by staying in network when seeking out healthcare services, as it may mean the difference between certain services being available to you or not.
The difference between “in network” and “out of network”
A “network” refers to the doctors, hospitals, and all other facilities (such as labs, pharmacies, etc.) that have a contract with a health insurance carrier. The contract allows the health insurance members to receive services at a negotiated rate. So for you to stay “in network,” you need to seek out services from physicians, hospitals, etc., that have a contract with your specific health insurance carrier. You receive the highest level of benefits when you stay within your network.
If you receive services from physicians, hospitals, etc., that do not have a contract with your carrier, it is considered going outside of your network. If you are out of network, you will not be receiving the benefits of your health insurance. It is extremely important to be aware of your health insurance plan’s rules, as some rules may change depending on the situation. As an example, the benefits available to you may be different when you receive healthcare services outside of your home state; meaning you may see a physician that has a contract with your carrier, but your plan does not allow you to receive the same benefits across state lines. This is not always the case, but it is an example of something to keep in mind when choosing a plan.
Financial benefits of staying in network for health insurance
The main purpose of provider networks is to save you money. When you use healthcare providers and facilities that are within your network, they can provide services at the rate negotiated by your insurance company. If you go outside of your network for healthcare services, the healthcare provider can charge whatever they want. Insurance companies will likely not cover any of the cost of services that are out of network, making the patient responsible for paying the full bill.
Depending on your plan, you could majorly save on things like copays, coinsurance, and deductibles. A copay is a fixed fee set by your insurance plan that you will need to pay to contribute to the shared cost of services split between you and your carrier. For example, if the copay for a standard doctor’s visit on your plan is $30, that is the amount you will pay each time you go to the doctor. This fixed rate will be different for different types of services.
Coinsurance is different in that instead of a fixed amount, you have a fixed percentage of the bill that you pay for services. For example, if you have a coinsurance of 20% and the total bill for seeing the doctor is $100, you will owe $20. Because the amount itself is not fixed, it will change depending on the total bill.
A deductible is the amount you will need to pay up front before your insurance kicks in. This can be paid as a higher annual fee or broken down into smaller monthly fees based on what works best for you.
Healthcare benefits of staying in network for health insurance
Health insurance companies uphold certain standards of healthcare quality for their members. This means that if you stay within your network, you can feel comfortable knowing you are receiving treatment that is of a quality high enough to reach this standard. Going outside your network means the same standards are not guaranteed. Receiving healthcare in your network also tends to be a much smoother and hassle-free experience, with less paperwork and waiting involved.
Additionally, you never want to sacrifice receiving proper medical treatment because of a hefty cost if it is something that can be avoided by staying in network. Services like lab work, MRI scans, etc., can be very costly. Going out of network for such tests can be so expensive that you are ultimately deterred from receiving treatment.
Always make sure you stay in network
Staying in network when seeking out healthcare services allows you to take full advantage of the benefits provided to you by your health insurance carrier. If you receive services outside of your network, the opposite is true, leaving you with a much higher bill and potentially not receiving the service you really need. Contact the Lighthouse Group today for any questions or concerns you may have regarding staying in network for your healthcare services!
How do I know what healthcare providers are in my network?
Most insurance companies will enable you to search for providers that are in your network on their website. You can also call your insurance company’s customer service number, which is typically located on your insurance card, for providers in your network. If you still aren’t sure, ask when you are scheduling your appointment!
