Out-of-Network Care: What You Need to Know About It

“Care” is defined as physicians and dentists, but also specialists like anesthesiologists, occupational therapists, and physical therapists. The services provided by hospitals, labs, radiology facilities, and pharmacies are also deemed care. If you are getting a complex procedure like a surgery, check to make sure all members of the team, particularly anesthesiologists and facilities like surgery centers, are in-network.

Out-of-network care can be expensive for many reasons, including:

  • An out-of-network provider may charge more for a service than an in-network provider.
  • Your plan may require you to make higher co-pays, deductibles, and co-insurance for out-of-network providers.
  • You may have to pay the full cost of out-of-network care yourself.

The term “balance billing” refers to when the insurer does not pay a portion of the bill. The consumer is left to pay the remainder of the bill.

Out-of-Network Care: The Basics

A health care plan typically covers only care and prescriptions given by individuals, institutions or organizations it has deemed in-network providers. These are offices that have agreed to be bound by the insurer’s contract. There are many reasons you may want to see an out-of-network provider. These include:

  • You want to continue receiving care from your current provider, which the plan has deemed out-of-network. If your provider leaves the network in the middle of treating you for a serious condition, you may be able to get coverage for the duration of the treatment.
  • You live in a remote area where there are no in-network providers for your condition.
  • In-network providers do not speak your native language and no medical translators are available.
  • You have been affected by a natural disaster and cannot see an in-network provider.
  • You have a rare genetic condition and there are no in-network providers close to you.
  • You are a college student who has moved away for school or a professional who must travel often. Plans may allow out-of-network care if there are “guest” or “travel” networks that extend coverage under these circumstances.

The services covered by a health care plan vary between states. This means that a procedure that is covered by a plan offered in California may not be covered by a plan offered in Oregon.

Best Practices

Here are general rules to follow about requesting out-of-network care:

  • When possible, work with providers that were formerly in-network. They will be familiar with the insurer.
  • Attempt to get pre-approval in writing from an identified member of the insurer’s staff. If you cannot, become familiar with the insurer’s appeals process.
  • Request that the provider state the arrangement for your care and payment in writing.
  • Request all referrals and pre-authorizations in writing. Provide these to your insurer.
  • If you are unsure about whether care is required, elective, or emergency, ask a doctor to state the final determination and reason why the care was required in writing.
  • Print out, organize, and retain all documents that contain assurances or promises regarding coverage and costs.
  • When a provider requires you to take an over-the-counter (OTC) medication, request that they provide a prescription in writing.
  • When you move between states, request information from your insurer about what is covered in your new state of residence.
  • Consult an attorney if the contract with your provider or insurer appears to be misleading or unfair to the point where a court would deem it unconscionable. An example of a problematic contract is one that contains “fine print” that is too small to read.
  • If you do not think a bill is fair or accurate, do not begin paying it. Talk to an attorney first.

Look up your in-network providers

Your network of health care providers is set by your insurer as well as your plan. The list of covered providers is subject to change.

Special rules regarding emergency care

The Affordable Care Act (ACA) maintains that insurers cannot charge more for co-pays and co-insurance for emergency services than they would for use of in-network providers. Insurers must also pay out-of-network emergency providers on a standard schedule. This reduces the chance that a consumer will be left with a large bill.

Using a Health Savings Account (HSA) and other payment options

A HSA is an account that you can use to pay for certain out-of-network health expenses. You can open an HSA if you are enrolled in a qualified high-deductible health plan (HDHP). A HDHP is subject to change at the direction of the IRS. In 2017, the deductible limit for a single person is $1,300. The deductible limit for an individual plus their family is $2,600.

A HSA allows you to contribute money from your paycheck to the account before it is taxed. Certain procedures require a Letter of Medical Necessity (LOMN) to be an eligible expense. An over-the-counter (OTC) drug requires a prescription to be an eligible expense. The IRS sets the contribution limit and determines what expenses are eligible.

You can also pay for out-of-network expenses with a flexible spending account (FSA) or health reimbursement arrangement (HRA). You cannot pay for out-of-network expenses with a limited care flexible spending account (LCFSA) or dependent care flexible spending account (DCFSA).

Generally, treatment by alternative healers for general wellness is not an eligible expense. Drugs, medicine, and treatment by alternative healers may be eligible expenses if a medical professional has made a diagnosis, determined such treatment is for a medical condition and has suggested or prescribed the alternative treatment.

How to get out-of-network coverage

1. Determine the reason you want to see this provider. Determine if you can explain why it is a medical necessity that you continue to work with this provider.
2. If you have a HSA or similar account, determine what you will need to prove the provider’s care is an eligible medical expense. This may include a doctor’s note, a LOMN, or a request for reimbursement.
3. Before you are treated, ask your provider for the medical insurance codes related to your procedure.
4. After you are treated, read the copy of your treatment document to determine what the medical codes refer to and if anything occurred that you did not expect. An example of such an event is a complication arising regarding surgery and the surgeon needing to engage in an additional procedure to ensure your health. Make sure the bill and codes are accurate.
5. If your request is denied, appeal internally. If this appeal fails, check state and federal law to determine whether you can appeal externally to an independent, outside group.
6. If you urgently need care and are financially challenged, ask for an expedited appeals process.


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