You don’t think much about your health insurance when you’re healthy. But knowing how your policy works when something goes wrong is essential. Out-of-network billings happen all the time and can be expensive, particularly if you didn’t know that a provider wasn’t part of your network before visiting them.
Luckily for patients and providers alike, though, there are ways to avoid getting hit with these bills in the first place. Here’s what you need to know about out-of-network services and how to stay protected.
What Are Out-Of-Network Billings?
Out-of-network billings are services that are provided by a provider who is not part of your insurance plan. For example, suppose you go to the hospital for an emergency but see a specialist in another city or state for a follow-up visit. In that case, that specialist’s services will be considered out-of-network billing.
Out-of-network providers may be more expensive than in-network providers. This can happen because they don’t have as many patients being seen as frequently and have no contracts with healthcare organizations to lower their rates.
If you use out-of-network services, often this could cause you to pay more than necessary over time since there isn’t any negotiation between the parties involved. In fact, in the most recent Commonwealth Fund Biennial Health Insurance Survey, forty-two percent of Americans said they had problems paying medical bills or were currently paying off medical debt.
Does Your Insurance Cover Out-Of-Network Providers?
To find out whether your insurance covers out-of-network providers, you can contact:
- Your insurance company
- Your employer’s benefits department
- The insurance commissioner for your state (you may be able to find this person or office online)
- Your state’s consumer affairs office, if one exists
The Affordable Care Act requires health plans sold through the Marketplace to provide enrollees and prospective enrollees with information about in-network and out-of-network providers.
How Can You Tell if a Provider Is Out Of Network?
When you receive a medical bill, it’s important to check whether the provider is in-network or out-of-network. This can be done by checking the following:
- The name of the provider
- The address of the provider’s office
- The phone number for their office, if they list one on their website
- If they are listed in your health plan’s directory as participating providers
- You may also want to ask your doctor if he or she is participating in your health plan before making an appointment with them
What Happens When You Choose an Out-Of-Network Provider?
If you choose to go out of network, you will be responsible for the full cost of those services. Your insurance company will not cover any portion of the charges for services rendered by an out-of-network provider.
Your insurance company may only pay a portion of what it considers “reasonable and customary” rates. This means that you will have to pay the difference between what your insurer pays and what the provider charges, as well as any copays or deductibles associated with their plan. The Congressional Research Service reported that Americans spent $389 billion out-of-pocket on health care in 2020.
In addition, many health plans limit out-of-pocket costs. Suppose these limits were exceeded in 2018 due to out-of-network care received before January 1st, 2019. In that case, they could affect your ability to enroll in new coverage during the open enrollment period of 2020.
However, as of 2022, the No Surprises Act can help save you from unexpected high medical bills even when you consult with out-of-network healthcare providers. The Act necessitates the insurance providers to inform you about out-of-network providers and the expenses they will cover if you get treated by them. Certain conditions must be met, but it may save you from paying high medical fees.
What Should You Do if You Receive an Out-Of-Network Bill?
If you receive an out-of-network bill, take these steps:
- Call the provider and ask them to negotiate a lower price. You may be able to get a discount if you can prove that your medical condition is severe.
- File a complaint with your state’s insurance department and attorney general. Some states require out-of-network providers to tell patients they won’t accept insurance from specific plans before treatment begins. In this case, the provider should give you information about how much of your bill will be covered by your health plan if they knew about it at the time of treatment.
- Insurance reimbursement is the process by which you can receive money back from your health insurance company through a check. You may be eligible to receive reimbursement if you’ve paid out-of-network charges for medical care provided by an in-network provider.
The reimbursement process can be challenging. Hence, it is always best to seek help from technology. There are many applications out there that can help you get reimbursement.
You can use an insurance reimbursement app to get help with filing a reimbursement claim. Insurance reimbursement apps help you keep track of your out-of-network medical expenses and ensure you receive the maximum amount reimbursed by your insurance.
Things You Can Do to Avoid Getting Billed
Out-of-network services can be pretty expensive, but there are a few things you can do to avoid getting billed.
Make sure your insurance company is covering the cost of your treatment. If your health insurer denies your claim, you can appeal the decision and have it reviewed by an independent third party.
If you’re unsure whether your insurance will cover the cost of treatment, contact them before visiting an out-of-network provider and ask whether they’ll cover it.
If your insurance doesn’t cover the cost of treatment at an out-of-network facility, ask about payment plans or financial assistance options before scheduling any appointments or procedures.
Hopefully, this article has helped you understand why out-of-network bills are so common and how to avoid them when possible. If you’re still unsure about what to do in a given situation, it might be time to call an expert, either an insurance agent or someone who specializes in billing and coding. Seeking help to avoid out-of-network bills can help you save a significant amount of money.