{"id":1772,"date":"2016-07-06T16:06:08","date_gmt":"2016-07-06T20:06:08","guid":{"rendered":"https:\/\/singlecare.com\/blog\/?p=1772"},"modified":"2026-02-08T19:28:32","modified_gmt":"2026-02-09T00:28:32","slug":"healthcare-defined-out-of-network","status":"publish","type":"post","link":"https:\/\/www.singlecare.com\/blog\/healthcare-defined-out-of-network\/","title":{"rendered":"What does \u2018out-of-network\u2019 mean?"},"content":{"rendered":"

You go for a routine appointment at a new doctor and\u2014BAM! You\u2019re hit with a larger than expected bill even with your health insurance coverage. You find out this high price is because the healthcare provider you used is out-of-network. But what does that mean? Let\u2019s find out!<\/span><\/p>\n

What does out-of-network mean?<\/span><\/h2>\n

Out-of-network describes a physician, hospital, or healthcare facility that is not a part of your health insurance company\u2019s provider network. This means that your insurance hasn\u2019t pre-negotiated a network rate with that physician, hospital, or facility, and you will be charged a larger percentage of the total medical bill or for the entire bill, depending on your particular health plan.<\/span><\/p>\n

All managed health plans have a network, including <\/span>Medicaid<\/span><\/a> and <\/span>Medicare<\/span><\/a>.<\/span><\/p>\n

Another blow from using an out-of-network provider is that typically these costs are not applied to your deductible if your plan does not cover out-of-network costs. They won\u2019t count toward your out-of-pocket maximum either.\u00a0<\/span><\/p>\n

Let\u2019s break this down when comparing out-of-network to in-network.<\/span><\/p>\n

In-network vs. out-of-network<\/span><\/h2>\n

When you sign up for a healthcare plan, the insurance company provides you with a list of doctors, hospitals, and healthcare facilities that are <\/span>in-network<\/span><\/i>. Visiting in-network providers for healthcare services will mean lower rates from as the insurance company and provider have negotiated rates. Unless your insurance company offers a generous out-of-network benefit, visiting out-of-network providers will mean your medical care expenses will increase as your insurance company will cover less or nothing at all.<\/span><\/p>\n

For example, you see your primary care provider because your sinuses hurt. She takes a look and recommends that you see a specialist. The total charge for that trip to the doctor is $100. Since she\u2019s in-network, a discount is applied to the total bill since your insurance has pre-negotiated a rate with that doctor. Let\u2019s say, the discounted total is now $80. You could be responsible for the remainder of the bill depending on your coinsurance and copay.<\/span><\/p>\n

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. Since that specialist wasn\u2019t in-network, no discount is applied to the total medical bill, and your insurance company either covers less, or worse, nothing at all since the provider was out-of-network and copays and coinsurance won\u2019t apply.\u00a0<\/span><\/p>\n

To see in- and out-of-network costs comparisons in your area, <\/span>this calculator<\/span><\/a> can help. It is often better to use an in-network healthcare provider, if possible, since the costs will be lower.<\/span><\/p>\n

It is also important to note that there are typically differences in cost between <\/span>health insurance plans<\/span><\/a> when dealing with in-network and out-of-network fees.<\/span><\/p>\n