What to Do if Your Doctor or Healthcare Provider Is Not in Your Health Insurer's Network

Negotiating your bill, using an HSA, and talking to your doctor are some of the steps you can take to keep medical costs down when insurance changes

Discovering that your preferred physician or treatment center is out of network can lead to surprise bills and stress. With medical costs rising faster than inflation and insurer networks shifting annually, you need a proactive strategy. By verifying coverage, leveraging federal protections, using tax-advantaged accounts, negotiating bills and tapping North Carolina-specific resources when appropriate, you can limit out-of-pocket exposure and protect both your health and your finances.

Verify Network Status Before Your Appointment

Insurer directories often lag behind contract changes. Always call your doctor’s billing office to confirm they are credentialed with your specific plan, not just whether they “accept” your insurance. Some providers accept multiple insurers but remain out of network for certain plans, meaning you face higher rates. Repeat this verification for any specialist referrals, labs, imaging centers and durable medical equipment suppliers.

Obtain a Written Good Faith Estimate

Under the No Surprises Act, uninsured and self-pay patients must receive a Good Faith Estimate detailing expected charges and patient responsibility. Even with insurance, request a similar estimate for any out-of-network services. A written estimate provides leverage in negotiations and clarity on potential costs before treatment begins.

Use Your HSA or FSA to Cover Costs

Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs) let you use pre-tax dollars to pay deductibles, co-insurance and out-of-network expenses. HSAs roll over annually and grow tax-free, while FSAs have limited carryover. Check your plan’s reimbursement process, submit claim forms promptly and keep receipts for every medical expense you incur.

Negotiate for In-Network Rates

Providers bill patients at “rack rates,” which can be 200 percent of insurer allowances. Ask your billing office to apply the insurer’s contracted in-network rate as your patient responsibility. Many will agree to reduce your balance if you offer to pay quickly or in full. Get any agreement in writing and follow up to ensure the correct rate is applied.

Request Financial Assistance or Charity Care

Nonprofit hospitals and community clinics often offer sliding-scale programs based on income. North Carolina hospitals must publish financial assistance policies online. Contact patient financial services to apply for discounts or payment waivers if your household income is below certain thresholds.

Ask Your Provider to Join the Network

If you have been a long-time patient, ask your doctor to reapply to your insurer’s network. Demonstrating patient demand can expedite credentialing. While this process can take months, it may restore in-network status for future visits.

Set Up a Payment Plan

Ask about interest-free installments. Even modest monthly payments, $50 to $100—can keep bills from entering collections. Negotiate fees and get the plan terms in writing to protect your credit score.

File an Out-of-Network Appeal

If your insurer wrongly classifies a service as out of network, file an internal appeal with medical records, Good Faith Estimates and provider confirmations. If denied, use your state’s external review. In North Carolina, contact the NC Department of Insurance Consumer Services at 1-855-408-1212 for dispute assistance.

Consider Telehealth or Virtual Care

Telehealth visits with in-network providers can substitute for in-person appointments when appropriate. Many plans waive telehealth copays, letting you continue care without network issues.

Plan Ahead During Open Enrollment

Review provider directories and call to confirm network participation before selecting a plan. If none of your providers are in network, factor potential out-of-pocket costs into your choice, balancing premiums, deductibles and network breadth.

Maintain Detailed Records

Create a folder, digital or paper—with appointment summaries, estimates, explanation of benefits, bills and correspondence. Date every entry and note representative names. Thorough documentation expedites appeals and prevents billing errors.

North Carolina-Specific Resources

North Carolina residents can explore Medicaid or NC Health Choice for expanded provider networks if eligible. For plan help, call the NC Medicaid Enrollment broker at 1-855-733-3711. The NC Department of Insurance enforces surprise billing protections and assists with out-of-network disputes.

By verifying network status, requesting estimates, using HSAs and FSAs, negotiating rates, appealing denials and using available assistance programs, you can manage unexpected medical expenses effectively. Taking these steps ensures you receive the care you need without jeopardizing your financial wellbeing.