You Picked a Doctor. But Are They in Your Network?

When my husband, Jarrod, was diagnosed with stage 4 colorectal cancer, his cancer specialist, also called an oncologist, insisted that he get a second opinion. He wanted Jarrod to see another oncologist so that Jarrod would be comfortable with and confident in the treatment plan. Because he had a PPO, Jarrod wasn’t just limited to in-network providers. He was able to choose absolutely any oncologist in the country.

Your network type determines which providers and hospitals are covered. Providers and hospitals are separated into two groups: in-network and out-of-network.

What are in-network providers and out-of-network providers, and why is it so important to know which is which?

In-network providers are providers who have a contract with your insurance company. Your insurance company agrees on a price with providers to get you lower prices. The insurance company lists providers as in-network providers when providers sign a contract with the insurance company agreeing to specific payment for specific services. You will pay less to see an in-network provider than an out-of-network provider because your in-network provider has already agreed to a specific price in their contract with the insurance company.

Out-of-network providers are providers who don’t have a contract with your insurance company. Because there is no agreed-upon price ahead of time, your cost is going to be higher with an out-of-network provider than an in-network provider.

Why is this important?

If you have an HMO or an EPO plan, you are only allowed to see providers who are in your network. If you want to go outside your network, you have to pay 100% of the cost. This is why it is so important to check first to make sure that your provider is in-network before your first visit.

With other network types, like a PPO or a POS plan, you are allowed to see providers who are out-of-network. The cost of seeing an out-of-network provider will likely be more than seeing an in-network provider, but your insurance will cover its part of the cost.

Your network type is either HMO, PPO, EPO, or POS. To better understand your network type, read my post HMO vs. PPO, Premiums, Deductibles...Finally Explained.

The two easiest ways to find out if a provider or hospital is in-network are to check on your insurance company’s website or to call member services and ask. A member services representative can quickly look up the provider or hospital and give you the answer right then and there. If you need to find an in-network provider, you can go to the insurance company’s website, and the insurance company will provide you with a list of providers for whatever specialty (specific type of doctor) you are searching for.

There are also in-network and out-of-network hospitals, so if you are having a planned hospital visit, check to make sure the hospital is in-network.

Now, in the case of an emergency, always go to the nearest hospital. I don’t want you to worry about whether a hospital is in-network or out-of-network if you have an emergency. You will not get charged extra if an ambulance takes you to an out-of-network hospital. If you have an emergency and are taken to an out-of-network hospital, you are allowed to remain in that hospital without having to pay more until you meet specific conditions. What are those conditions? There are four parts.

• You have to be able to be told you are at an out-of-network hospital.
• You have to be able to understand that you are at an out-of-network hospital.
• You have to be able to make the decision to go to an in-network hospital.
• You have to be able to be moved to the in-network hospital without medical treatment being given to you while you are being moved.

If all four conditions are met, and you choose to stay at the out-of-network hospital, you will be charged for the difference in cost of an in-network and an out-of-network hospital. If you have an HMO or EPO, that means you will be paying cash for the rest of your hospital stay.

Now that you know the difference between in-network and out-of-network providers, you can make sure that you don’t end up with a surprise bill because you accidentally saw an out-of-network provider.

If you learned something from this post and want to learn more, there are two paths: the Decoding Healthcare Program or 1:1 Guidance Sessions. In October, I’m releasing the full education program, Decoding Healthcare. Upon completion of the Decoding Healthcare Program, you will have gone from unsure to informed, overwhelmed to organized, unheard to in control, and frustrated to strategic.

Join the waitlist now on my website, www.healthcareuncomplicated.com/waitlist, and you’ll get my Free Guide: 10 Questions To Ask Before You Pay A Medical Bill. If you sign up now, you will also unlock the special early-bird price for the program.

If you need help immediately, I have 3 spots left for clients to work one-on-one with me. All you have to do is sign up for a free 15-minute consult. During the call, I will assess where you are in your health care journey, ask you some questions and answer yours, and evaluate whether you are a good fit for the one-on-one sessions. Either way, you will leave the call knowing your next steps. Sign up for your free 15-minute consult.

Coming in 2 weeks: Parts A, B, and D: Do You Actually Know What You're Paying For?

Definitions

Oncologist: Cancer specialist

PPO (Preferred Provider Organization): A type of insurance network that allows the patient to see a specialist, like a lung doctor, directly without having to see a primary care physician first and covers in-network and out-of-network providers.

Specialist: A provider who specializes in one body part or body system, like a heart doctor

In-network provider: A provider who has a contract with your insurance company

Out-of-network provider: A provider who doesn’t have a contract with your insurance company

Primary care physician: A provider who specializes in general medicine and treats common medical problems and everyday illnesses

HMO (Health Maintenance Organization): A type of insurance network that requires the patient to see a primary care physician before seeing any other specialist and only covers in-network providers.

EPO (Exclusive Provider Organization): A type of insurance network that allows the patient to see a specialist without having to see a primary care physician first but only covers in-network providers.

POS (Point of Service): A type of insurance network that requires the patient to see a primary care physician before seeing a specialist but covers in-network and out-of-network providers if the patient gets a referral from their primary care physician to see the out-of-network provider.

Referral: A formal recommendation for you to see another provider

Frequently Asked Questions

What is the difference between in-network and out-of-network providers? In the simplest of terms, an in-network provider has a contract with your insurance company and an out-of-network provider does not.

If I have an HMO, do I have to stay within my network? Yes. If you want your insurance company to pay its part, you have to see an in-network provider.

If I have a PPO, do I have to stay within my network? No. Insurance will pay its part for in-network and out-of-network providers.

If I have an EPO, do I have to stay within my network? Yes. Your insurance will only pay its part if you see in-network providers.

If I have a POS, do I have to stay within my network? No. As long as you get a referral from your primary care physician first, you can see an out-of-network provider, and your insurance company will pay its part.

Why is it more expensive to see an out-of-network provider? Your insurance company agrees on a price with an in-network provider long before you ever see that provider. Your provider has already accepted a set payment from your insurance company, and that amount is less than what an out-of-network provider will accept from the insurance company.

If I have an emergency, do I have to go to an in-network hospital? No. If you have an emergency, go to the nearest hospital regardless of whether it is in-network or out-of-network.

If an ambulance takes me to an out-of-network hospital, will my insurance cover it? Yes. Because the law requires it, your insurance must cover its part of the hospital bill as if it were an in-network hospital for the amount of time that you are in crisis. Once you are out of the crisis, you must switch to an in-network hospital. You are out of the crisis when: you are able to be told that you are at an out-of-network hospital, you can understand that you are at an out-of-network hospital, you are able to decide to go to an in-network hospital, and you can be moved to an in-network hospital without receiving medical treatment while being moved.

Healthcare Uncomplicated provides general health system education only and does not offer medical or legal advice. Always consult a qualified professional for your specific situation.

Coming in 2 weeks: Original Medicare