When you go to the doctor or have to visit a hospital, you expect them to take your insurance and choose appropriate in-network physicians to care for you. However, you may not realize that you are being treated by an out-of-network anesthesiologist, surgeon, or other physicians in an emergency.
Unfortunately, hospitals and other care facilities may staff various care providers that may be considered out-of-network for some individuals. In these situations, you or a loved one must make it known that you do not want to receive care if the practitioner is out of your network. However, that may mean you have to wait to receive treatment.
So, how can you avoid out-of-network charges? Before diving into tips on avoiding out-of-network anesthesiologists and other providers, it’s crucial to understand the difference between in-network and out-of-network.
Understanding In-Network vs. Out-of-Network
When you choose your preferred insurance provider and plan, you are agreeing to a contract to work with a group of individuals and facilities that have agreed to specific terms and conditions, stating that they agree to only charge so much for specific services.
Two important terms you’ll want to pay meticulous attention to are in-network and out-of-network.
In-Network
The term in-network refers to facilities and providers that are a part of your insurance provider’s network of providers. These parties have negotiated contracts with your insurance provider to provide specific services at a lower cost, resulting in discounted prices for those who use these in-network providers.
Out-of-Network
The term out-of-network simply refers to any facility or provider that hasn’t agreed to any contract with your particular insurance provider. That means that there are no discounted rates, and these facilities/providers can charge their standard prices for any and all services.
Can a Facility Be In-Network but Have Out-of-Network Staff?
The answer is yes – especially in the case of hospitals and clinic settings.
How can that be? While many facilities only hire staff that will agree to the terms and conditions of the insurance providers they work with, many institutions work with physicians who are independent contractors. This allows them to decide which insurance providers they are willing to work with and which ones they aren’t.
This is especially true in the case of walk-in clinics and emergency room departments. While the general facility may say they accept certain insurance policies, they may be stating that as a blanket term referring to the fact that only some of their practitioners will accept it. Unfortunately, that means some individuals may assume that all doctors in the facility accept their insurance and don’t question who treats them.
What Happens When You Use an Out-of-Network Doctor or Anesthesiologist?
When you are in a hospital setting, it can be rather chaotic. If you don’t make it explicitly clear that you only want to work with a doctor or anesthesiologist in your insurance network, you may unknowingly be seen by someone outside your network.
If that’s the case, these individuals can charge you full price for the services they provide you with, which means your bill can wrap up very quickly. While some insurance types are willing to pay a portion of these costs, some will outright deny any out-of-network charges, leaving you to foot the bill in full.
How to Avoid Out-of-Network Charges
Sometimes out-of-network charges can seem completely unavoidable, such as the case in emergency room situations. However, if you do some research and take these six steps, you may be able to void out-of-network charges:
1. Understand Your Insurance Benefits in Full Before Seeking Out Services
The first step in avoiding out-of-network charges is to take responsibility and understand your insurance benefits in full.
Unfortunately, millions of people sign up for a plan without taking the time to investigate what all it covers, what it doesn’t, etc. Then, when they go to use their insurance, they are surprised to find certain physicians are marketed as out-of-network, and their services weren’t covered – leaving them to pay for the services in full, out of pocket.
When choosing your plan for the year, you must know what you are agreeing to. It’s also essential to revisit your plan’s documents before you seek out any services from a provider you are unfamiliar with to ensure that your plan covers them.
2. Inquire About the Standing of Your Preferred Provider
When signing up for your plan, you want to double-check that your preferred provider is still accepting your insurance. Just like patients, many physicians are given the opportunity to renew or select a new contract with insurance providers annually. Regrettably, your providers are not required to send out notices to patients that they no longer accept certain plans. This is why you must check with your insurance provider and see if your preferred physician is still considered in-network or if they’ve ended their contract with your provider and moved to out-of-network.
Should your provider no longer be considered in-network, then you can use your insurance provider’s website to research physicians who are covered.
3. When Being Referred to Specialists, Always Ask for In-Network Options
When seeking out advice on something outside your standard yearly checkup, your doctor may refer you to a specialist that they believe can better address your needs. In these cases, you want to make it clear that you only want to be referred to an in-network specialist.
In most cases, your provider will be able to help you find someone in your network. However, if they can’t, it’s up to you to inquire with your insurance provider about in-network specialists.
4. If You Can’t Find an In-Network Solution, Ask for Costs of Services Upfront Before Your Appointment
If you are still running into issues finding an in-network option and need to act sooner rather than later, you want to make sure you ask for the cost of services upfront. When you ask for these costs before your appointment, it allows you an opportunity to shop around and see if you can’t find cheaper alternatives.
5. Inquire About Gap Insurance Options with Your Insurance Provider
When you think of gap insurance, you likely think of auto insurance. Although did you know that you can invest in gap health insurance as well? These plans are supplemental plans that can help with:
- Critical illness
- Injuries
- Accidental death and dismemberment
You’ll want to have adequate time to research your options and see what you can fit into your budget.
6. When Necessary, Ask the Provider/Facility What Financial Assistance is Available
If you don’t have a gap insurance option and you are faced with a bill from an out-of-network provider, you want to ask about any financial assistance that may be available. This is especially important if you fall under financial hardships. In these cases, most facilities will be more than happy to set up a repayment plan and, in some cases, may be able to forgive a portion of your debt.
Frequently Asked Questions: In-Network vs. Out-of-Network
To get the most out of your insurance policy, it’s essential to understand your policy inside and out. While you may understand the basics of your plan, you’re bound to come across something that leaves you scratching your head. Here are some of the most frequently asked questions that policyholders often find themselves asking:
Does Insurance Pay for Out-of-Network Services?
This will depend on the type of policy you have. If you’ve invested in supplemental gap health insurance, then you may be able to apply these benefits towards out-of-network services. If you don’t have any gap insurance, check your primary policy’s fine details because some providers will cover a certain percentage of out-of-network services.
Does PPO Cover Out-of-Network Services?
Preferred Provider Organization (PPO) plans do include out-of-network benefits, whereas other plans, such as Health Maintenance Organization (HMO) plans, do not. While PPO plans do include out-of-network benefits, you’ll want to refer to your plan’s details to see what benefits are provided and how much will be covered.
Can an ER Be Out-of-Network?
Yes – an emergency room/hospital can be out-of-network. That means that this hospital decided not to sign a contract with your insurance provider, allowing them to set their own fees for services. The same can be said of those the hospital employs. Since many ER doctors are independent contractors, they can decide which insurance providers they choose to work with. When a patient is rushed to an ER, they are often faced with bills for out-of-network anesthesiologists and other physicians because they cannot express their desire to be treated by in-network individuals.
What is a RAPs Provision?
A RAPs provision refers to a provision in your current insurance plan that will pay out-of-network radiologists, anesthesiologists, and pathologists (as well as some ER physicians and other specialists), in the case that you cannot receive necessary treatment from someone in-network. These are most often provided by PPO plans that include out-of-network benefits.
Are Anesthesiologists Ever In-Network?
Yes, there are many cases when an anesthesiologist is in-network. Unfortunately, many patients don’t choose who they can work with because a facility only employs certain individuals or has only specific people on call for these specialties.
This is why it’s vital to do your research before an appointment to see who is covered and, if they aren’t, where you may be able to go for an in-network specialist or what financial assistance you may be entitled to.
What Happens If You Never Pay Your Hospital Bill?
When patients receive a surprise bill from an out-of-network anesthesiologist or another practitioner, they often refuse to pay the bill. This may be because they had no choice in cheaper options, such as during emergencies, or they simply don’t agree with the bill.
Unfortunately, if you decide not to pay your bill, the hospital will likely send your unpaid balance to collections. Once it moves to collections, it will be reported to the major credit bureaus and can significantly impact your credit score, affecting you in many ways, such as applying for a loan for a vehicle or home.
If you legitimately cannot pay your hospital bill for some reason or another, you should always reach out to the hospital and see what they can do to help you out. They might be more than understanding and help you set up a payment plan. In the cases of extreme financial hardships, they may choose to forgive a portion of your debt owed.
Know Your Policy to Avoid Out-of-Network Anesthesiologists and Doctors
Paying out-of-network anesthesiologists or other physicians can be quite expensive. That’s why you must take the time to adequately research all of your insurance options before locking yourself into a contract.
Once you’ve decided on a plan that works for you, make sure you take the necessary time to see what facilities and physicians are considered in-network. Even if you don’t think you’ll need a specialist anytime soon, it’s wise to look into your choices just to be aware of your options.