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How to Go Out-of-Network for Health Insurance

Not all doctors accept every health insurance plan. Some doctors choose not to accept any health insurance. This allows them to control the amount charged and the billing process, and gives them the freedom not to conform to network standards. Some health insurance plans allow for out-of-network services, including many preferred provider organizations. Others, such as health maintenance organizations, do not pay for any out-of-network services. Everyone has the right to go out-of-network; however, there are many reasons to stay in-network.

  1. How It Works

    • Anyone can choose to see the doctor of his choice. Going out-of-network to see any doctor simply requires making an appointment and visiting whoever you want to visit. However, you need to recognize that your insurance may not pay for any out-of-network services. Even if they do pay, the cost of the visit may be substantially higher than if you went to an in-network provider.

    Advantages

    • Seeking out-of-network care allows the insured the freedom to visit any doctor, hospital, provider or facility of her choosing. Advantages to going out-of-network include no need to obtain referrals for services or get insurance pre-authorizations, no limitations to a geographical area for receiving care and no restrictions on which hospitals to use. In addition, many insurance plans cover a portion of out-of-network care. Another major advantage to the patient is confidentiality. If the patient is not submitting claims to the insurance company, knowledge of the services rendered stays between the patient and the provider.

    Disadvantages

    • The primary disadvantage to utilizing out-of-network services is higher cost. Even when the insurance company covers out-of-network services, the coverage is reduced and much less than the in-network level. When there is no out-of-network coverage, the patient is responsible for paying the total bill. Not only may these fees be higher than usual, but providers may also require up-front payment. The responsibility to submit claims to the insurance company is the patient's, not the provider's. The provider can bill the patient directly, often for whatever amount he wants to charge.

    Bottom Line

    • Going out-of-network is as easy as calling the doctor and seeing whoever you want to see for your care. But realize that this may cost you significantly more than utilizing an in-network provider. Always check with your insurance company to confirm a provider's status, and ask out-of-network providers about fees and payment options prior to seeking their services. Additionally, seeing a network provider may give you peace of mind, as network providers have agreed to reimbursement rates and gone through a thorough review by the insurer of their credentials.

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