Out-of-Network Reimbursement

Although it may initially cost more money, there may be times when it is necessary, or even advisable, to use an out-of-network provider. Sometimes you have no choice, or it just makes sense to choose a non-network healthcare provider due to the nature of your illness. In this article, we’ll outline some of the primary reasons why a person may select an out of network provider.

Out of Network Provider Care

An out-of-network provider is one which doesn’t have a contractual agreement with your insurance company for reimbursement at a discussed rate. Few health plans, like HMOs and EPOs, don’t reimburse out-of-network providers at all (except in emergency situations). This means you would be accountable for paying the full medical costs of the physicians services. Other health plans offer coverage for out-of-network providers, but your patient responsibility is higher than it would be if you were seeing an in-network provider. Even with all of these considerations in play, there are times when you have to go with a doctor or clinic outside your insurers network. Below are a few of the primary reasons why a patient might go out of network: 

Emergencies: As the saying goes, life can come at you fast, and in situations where urgent care is needed, you will have to find help wherever you can. This may often require getting medical attention from out of network doctors or hospitals. Thankfully, the Affordable Care Act (ACA) requires insurers to cover emergency care as if it’s in-network, regardless of where emergency care is obtained. Despite this provision, out-of-network emergency rooms and physicians can still send you a balance bill. Furthermore, balance billing is not restricted by the ACA (although some states have restricted it). 

Specialized care: If you are suffering from a rare illness for which there is no specialist included in your plan, out-of-network care may be crucial. These illnesses can include, but are not limited to, autoimmune diseases, uncommon cancers, degenerative disorders and birth defects.

Changing providers would jeopardize your health: What happens if you’re in the middle of treatment for serious or end-of-life issues and your provider leaves the network?  In this case, a patient might opt to continue that care by going out of network. Some insurance providers might give you the option to appeal for continued in-network coverage, but outcomes can vary.  Most likely the company will allow in-network coverage  for a short period of time or a set number of visits.

Out-of-town care: Should you need medical care while away from home, you may have to go out of network. In some instances, insurers will handle your visit to a non-participating provider as if it were in-network. If the health concern is non-critical, it may be best to seek out In-network providers whenever or wherever available. It’s best to contact your insurer first to learn about local availability if time allows.

Proximity issues: The ACA requires insurers to maintain provider networks based on an adequate, reasonable distance that patients have to travel to reach a medical provider. The guidelines on what constitutes adequate varies from one state to another. If you live in a rural area and there is no realistic access to an in-network provider, you may have to depend upon a non-participating doctor. In such cases, you may be able to appeal to get coverage for an out-of-network provider in your area.

Natural disasters: Floods, widespread fires, hurricanes, and tornadoes can destroy medical facilities and force people to evacuate in order to seek safety and health care. After a Declaration of Emergency by the state or federal government, disaster survivors may be eligible for in-network rates.

Evaluating Balance Billing

Out-of-Network providers can still bill you, even if your insurance covers some of the cost. This often occurs in spite of the fact that your insurance company treated your out-of-network care as if it’s in-network. Federal law does not require any out-of-network provider to accept your insurance company’s payment as payment in full. 

Let’s say your insurance company has a “reasonable and customary” rate of $500 for a certain procedure, and you’ve already met your in-network deductible. An unforeseen situation occurs and you end up in a position where an out-of-network provider performs the procedure. Your insurer agrees to pay the $500, however, if the out-of-network provider charges $800 for the service, you would be responsible for the remaining $300 dollars. 

Some states have attempted to tackle this issue, including Florida (out-of-network providers who work at in-network hospitals) and New York (emergency situations). Despite these efforts, balance billing is still a problem for patients who receive care outside their insurer’s network.

Network Adequacy Regulations

The ACA and related regulations have implemented rules that apply to plans sold in the health insurance exchanges. These plans are required to maintain adequate networks and up-to-date network directories online. In 2017, the Trump Administration began deferring to the states for network adequacy determinations, weakening the enforcement of network adequacy standards. Subsequently, people buying coverage in the individual market find that networks are generally smaller than they were in the past. For this reason, it becomes essential for enrollees to double-check the network of any plan they’re considering if they have a specific doctor in mind.

In the small group and large group markets, states also have the ability to review plan filings to ensure that the networks are adequate. In spite of this leverage, employers tend to have considerable input when working with insurers, especially in the large group market. Often times, they try to make sure that the plans they’re offering to their employees have adequate provider networks. This does not mean that there won’t be cases where an out of network provider won’t be essential to care.

When it comes to your insurance coverage, it’s great to have options, still, patients must be prudent in their choices to keep medical costs low. To that end, there are numerous tools available, both off and online, that can help with healthcare based decision making. With such elements in place, consumers can hopefully figure out what works best for their circumstances, and plan accordingly if they have to go out-of-network.