Is Your Healthcare Provider Out of Your Insurer's Network? Here's What to Do

Negotiating, using an HSA, and talking to your doctor are some of the steps you can take

Nurse with Patient in Wheelchair / Is Your Healthcare Provider Out of Your Insurer's Network? Here's What to Do
Image: Pixabay
April 25, 2017

It happens all too often: you go to see a doctor in the belief that he or she is in your insurer's network, only to find out afterward that the doctor was out-of-network when you get a huge bill. What can you do?

It's hard enough trying to figure out what your insurance policy does and does not cover. When you then have to determine which doctors will take your insurance and which won't, it's almost enough to make you throw in the towel just to be done with it all.

Don't give up! As frustrating as insurance can be, it's a necessary evil, and there are steps you can take to make sure that you spend as little as possible even when your doctor is out-of-network.

If You Already Have the Bill

Even if you've already gotten the bill for your doctor's visit, all is not lost. Try these tips to minimize your expenses:

  1. Talk to the doctor
  2. Sometimes doctors and their representatives give patients incorrect information about insurance coverage. Most do not do this intentionally, but there are some who do it knowingly. Either way, if what they told you ends up being wrong, contact them immediately. Many will honor the price they told you, and others will at least give you a big discount.

    Don't give up if they don't get back to you right away. Keep trying for a lower price and your persistence will pay off—if only to get you to stop contacting them!

  3. Negotiate
  4. Most doctors have different rates for insurance companies than for individuals paying out of their own pockets. If your insurance won't cover your doctor's visit, call the doctor's billing department and request the self-pay cost.

    "Most physician offices will accept a lesser amount," said health insurance agent Natalie Cooper. "Especially if they know the service is not going toward a deductible."

    If you can't afford to pay the full balance at one time, ask about payment plans. Most doctor's offices would rather get the money in smaller installments than not at all.

    "Most physician and hospital groups will accept a small payment of $25 or $50 per month until it's paid off," said Cooper.

  5. Pay with a health savings account
  6. If you're having trouble paying a medical bill out of your own pocket, find out if you can open a health savings account (HSA) and use that money to pay it. For instance, if you owe $2,000, you can transfer that amount to an HSA and then pay the bill directly from that account. Plus, any contribution you make to an HSA is tax deductible!

If You Haven't Gone to the Doctor Yet

Although there are things you can do to offset the cost of vising an out-of-network doctor after the fact, it's best to prevent those expenses in the first place. Here's how to do it:

  1. Ask before you go
  2. Insurance companies often provide lists of in-network doctors on their website, but unfortunately those lists are often out of date. The only way to make sure your doctor is in your insurer's network is to directly call their office and ask if they're a network provider—not just if they accept your insurance.

    "When they are a network provider, they are contractually required to accept no more than the negotiated contracted rate as payment in full, which is usually less than the billed rate," said human resources expert Laurie A. Brednich. "When they say they 'accept xyz insurance,' they are usually not a network provider, but will file the claims on your behalf, and you are responsible for the full billed charges."

    It's also a good idea to provide the doctor's office with your insurance group and account numbers before you visit so there will be no question about your particular policy. The more specific you can be, the easier it will be to get through the insurance maze.

  3. Find out which procedures and doctors are covered
  4. Have you ever visited a doctor who recommended that you go to a specialist for a certain procedure—only to discover that the specialist is not covered by your insurance?

    When doctors make these referrals, they are not confirming that the specialist is covered in-network by your insurance policy. Before you even make the appointment, find out from the billing department what their policies are. Ask them for a written estimate beforehand so you'll have some idea of the costs involved.

    Be aware that your insurance may not cover certain procedures even when it's your in-network doctor who is ordering them. If that doctor sends your results to a lab, that lab may not be in your network even if the doctor is.

    Find out whether the lab is covered before you have the procedure. If you already had the procedure, call your insurance company and tell them you didn't know that the lab would not be covered, then ask if they can bill the procedure as in-network.

    If they refuse to do so, call your doctor's office and explain the situation. Ask why they used an out-of-network provider and if they would be willing to write off the bill. Be polite, but be firm as well.

  5. Ask your doctor to apply
  6. You can ask your doctor to apply to your insurance company to be covered in-network if your insurance changes policies. If you decide to try this step, ask as soon as you find out that your insurance has changed.

    You may have more luck with this if you've been seeing your doctor for a long time than if you haven't established a long-term relationship yet. Even if you've only been seeing the doctor for a short time, however, it never hurts to ask.

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