You might need to use an out-of-network provider for several reasons. Maybe you experienced a medical emergency and had to be treated at the nearest hospital. Or perhaps you needed to see a specialist, but the closest one in your network was hundreds of miles away.
Whatever the reason, health care costs associated with a provider outside of your insurance network can be expensive. But you may not need to foot the whole bill.
Below, you’ll find out how to deal with out-of-network insurance charges, including how to tell what your insurance policy does and doesn’t cover, how to negotiate out-of-network charges, and how to avoid billing surprises. Make sure you’re covered when getting medical treatment without paying extra money out-of-pocket.
- The type of insurance plan you belong to determines whether out-of-network charges are covered and to what extent.
- Receiving care from an out-of-network provider can be expensive, especially if you belong to an HMO.
- Your "summary of benefits and coverage" (SBC) gives you a snapshot of what services are covered, cost sharing, and any exceptions.
- If you experience an emergency, you might be covered for some out-of-network care.
What Is an Out-of-Network Charge?
Most insurance plans have a provider network, which is a group of doctors, hospitals, and other care providers under contract to provide medical care to its members at a discounted rate. Insurance companies offer different plan types that have different networks.
If you seek care from a provider outside of plan's network, your insurance may not cover the cost (or won't cover as much of it) and you’ll incur out-of-network charges for the services you received.
How To Tell What Your Insurance Covers
The type of insurance plan you belong to will determine what types of providers you can see and how much you need to pay if you go out of network. For example, if you belong to a health maintenance organization (HMO), you can generally only visit providers within the HMO’s network, and you may be required to live or work within its service area to be eligible for coverage. You aren’t generally covered for out-of-network care, except in case of an emergency or with a referral from your primary care physician (PCP).
If you belong to a preferred provider organization (PPO), you pay less if you visit a provider within the plan’s network, but you can also use a provider outside of the network without a referral for a higher cost.
Since it can be expensive to receive care from an out-of-network provider, it’s important to find out exactly what your health plan covers.
Review your "summary of benefits and coverage" (SBC) for a snapshot of your health plan's benefits, including what services are covered, cost sharing, and any exceptions. Your health insurance company or employer should have provided one when you enrolled in your plan.
If you've misplaced the SBC and can’t find it on the health plan's website, you can request a new copy at any time from your insurer or employer, Louise Norris, a licensed broker and analyst for healthinsurance.org, told The Balance in an email. “The SBC should give you a good idea of exactly how your coverage works, but you can also call the health plan directly to ask specific questions about your coverage,” she said.
How To Negotiate Out-of-Network Charges
Ideally, you should avoid out-of-network services to prevent large medical bills. That means checking to make sure that any medical provider you're going to use is in your health plan's network. “That's something you'll want to do any time you're making an appointment, as provider networks can change, even mid-year,” Norris said.
If you have an HMO, be sure to get a referral from your primary care physician for any specialists you need to see to avoid or limit out-of-network charges.
Ask for an Exception
However, it’s not always possible to avoid out-of-network charges. If you know you're going to need to seek care from an out-of-network medical provider, Norris said you may be able to negotiate with your insurer to get a network exception.
One situation that may warrant a network exception is when there are no in-network providers within a reasonable distance. Another is when the out-of-network provider has a level of expertise that's superior to the available in-network providers for a particular procedure.
“These sorts of exceptions are fairly rare, because insurers are required to maintain adequate networks,” Norris said. “But it never hurts to ask.”
Negotiate With the Provider
If you know you're going to be paying for the out-of-network care yourself, you can try to negotiate a lower price directly with the medical provider. Norris explained that they may offer you a discounted rate in exchange for paying cash or for agreeing to a short payment time frame.
When negotiating your medical bill, it’s important to maintain a calm and polite demeanor. It also helps to keep a paper trail of your conversations. Always get the name of the person you’re speaking with, and follow up with an email containing notes from your conversation. That way, if a verbal agreement is ever disputed, you have it in writing.
Common Surprises That Complicate Insurance Billing
Even if you do your best to choose in-network hospitals and doctors, you may be met one day with a surprise out-of-network bill.
For example, if you experience a medical emergency, you could be taken to and treated at the nearest hospital regardless of whether it’s in-network. Or if you’re having surgery at an in-network hospital, the anesthesiologist or assistant surgeon could still be out-of-network. If this happens, you could be left with a bill for the difference between what the provider charges and what your insurance pays, which is known as “balance billing.”
Fortunately, the No Surprises Act will take effect in 2022, protecting people from most of these types of surprise bills. “This legislation will mean that consumers will no longer be left on the hook for out-of-network charges in emergency situations or if they receive care from an out-of-network provider while at an in-network facility,” Norris said.
What Can I Do About an Excessive Out-of-Network Charge?
If you visited an in-network facility and unknowingly received care from an out-of-network provider or had to use an out-of-network provider in an emergency situation, Norris said that the state insurance commissioner might be able to step in and help with out-of-network expenses.
Although federal rules to address surprise medical bills don't take effect until 2022, numerous states have implemented rules to protect consumers in these situations (state rules only apply to state-regulated plans, which do not include self-insured group plans).
If the state insurance regulator can't help and you aren’t able to negotiate a lower rate, you may have other options. Ask the facility or provider about any assistance programs they offer for patients who can demonstrate financial hardship. Also ask about assistance programs that help cover co-pays, in general, or for specific diseases. If you need help with the cost of prescription drugs, you may be able to qualify for a state drug assistance program through your state commissioner’s office.
Frequently Asked Questions (FAQs)
How much do insurers typically charge for out-of-network services?
The cost of out-of-network services can vary dramatically. One study by industry trade group America’s Health Insurance Plans found that bills for common services performed outside a plan’s network ranged from 118% to 1,382% higher than what Medicare paid for the same services.
Is there a limit to how much out-of-network doctors can charge?
When doctors contract with health insurance companies as part of a provider network, they typically agree to offer discounted rates to that health plan’s members. But out-of-network doctors aren’t limited by the same contractual obligations, Plus, an out-of-network provider’s charges won’t apply toward your plan’s out-of-pocket maximum, so you could pay far more than what you would have for in-network charges.