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Healthcare Defined: “Out-of-Network”

Cropped SingleCare logo By | July 6, 2016

Sometimes, healthcare can seem like a whole different language. In this series, we break down some common healthcare terms into plain English.

Out-of-Network (noun) — Describes a physician, hospital or healthcare facility that is not a part of your insurance company’s network. This means that your insurance hasn’t pre-negotiated a rate with that physician, hospital or facility, so you will be charged a larger percentage of the total medical bill or for the entire bill, depending on your particular plan.

Let’s break this down.

When you sign up for a healthcare plan, the insurance company provides you with a list of doctors, hospitals and healthcare facilities that are in-network. Visiting these providers when sick will mean lower rates from both the insurance company and provider. Visiting providers outside the network will mean your medical expenses will increase as your insurance company will cover less.

For example, you see your general practitioner because your sinuses hurt. He takes a look and recommends that you see a specialist. The total charge for that trip to the doctor is $100.00. Since he’s in-network, a discount is applied to the total bill since your insurance has pre-negotiated a rate with that doctor. So, if the discount is $20.00 and your insurance pays $40.00, you’re only responsible for $40.00 of the total medical bill.

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However, after doing some research, you realize that the conveniently-located specialist you need to see is out-of-network. You decide to take the risk and book an appointment. A few weeks after the visit, you get a bill for $250.00. Since that specialist wasn’t in-network, no discount is applied to the total medical bill, and your insurance company either pays less, or worse, nothing at all.

Even though the in- and out-of-network systems may seem logical, insurance companies don’t make it easy. Sometimes the in-network list is extremely long and hard to navigate. Additionally, the providers you’re allowed to see vary between insurance companies. You could have an in-network gynecologist that you’ve been seeing for 10 years, but after starting a new job and changing your insurance, she becomes out-of-network, and you may no longer visit because you can’t afford the extra costs.

At SingleCare, we believe you should be able to get the care you need and see the doctor you want without breaking the bank. On our website, you can view and compare provider rates that work for your wallet, so you can focus on improving your health instead of worrying whether a doctor is in- or out-of-network.