How to be Sure a Healthcare Prover is In-Network

Just Because a Provider Takes Your Health Insurance Doesn’t Mean It’s In-Network

Receptionist and patient talking.
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If you have an HMO, PPO, EPO, or POS health plan, getting care outside of your plan’s provider network can cost you a lot more money than staying in-network. But, it’s not always easy to figure out whether the provider you’re seeing is in-network or out-of-network with your health insurance, especially when you’re not able to sit down at your computer and visit your health plan’s website.

If you’re making an appointment with a new provider, you can always check its network status before your appointment and cancel the appointment if you discover it’s out-of-network.

However, if you’re getting unplanned health care, you may not be inclined to take the time to check whether or not the provider you’re about to use is in-network. This situation can arise when you’re getting care at an urgent care center, a walk-in clinic, a retail clinic, or even if you’re getting an X-ray or lab work done on your way home from the doctor’s office.

In these situations, you might be tempted to ask the provider, “Do you take XYZ health insurance?” When the receptionist answers, “yes,” you’d like to think you’re using an in-network provider. But, you could be mistaken and that mistake could cost you big-time. Just because a provider accepts your health insurance doesn’t necessarily mean that it’s in-network with your health plan.

What Accepting Your Health Insurance Really Means

To a health care provider, accepting your health insurance means

  • It will file a claim with your health plan.
  • It will accept any money your health plan pays.
  • It will credit payments from your health plan toward your bill.

It does not necessarily mean that it’s an in-network provider with your health plan.  In fact, a provider doesn’t have to be in-network with any health plan, yet it can still accept all types of health insurance.

What Being In-Network Really Means

When a health care provider is in-network, it means a lot more than that it will accept your health insurance. It means

  • It will honor the discounted rates your health plan has negotiated with it.
  • It will accept your health plan’s payment combined with your copayment, coinsurance, or deductible as payment-in-full.
  • It will not balance-bill you for in-network, health plan covered services.
  • If it has a problem with the allowed amount designated by your health plan for the service it provided, it will take that issue up with the health plan rather than with you.
  • It has passed your health plan’s credentialing process which usually includes things like education and license verification and quality checks.
  • It will file a claim with your health plan.
  • It will accept any money your health plan pays.
  • It will credit payments from your health plan toward your bill.

Why an In-Network Provider Is Better Than a Provider That Merely Accepts Your Insurance

Now that you understand that being in-network and accepting your health plan aren’t the same thing, you need to understand why being in-network is better than merely accepting your health insurance.

When you use an in-network provider, you have several protections that you don’t have when you use an out-of-network provider that accepts your health insurance.

An out-of-network provider can bill whatever it wants for its services. If an out-of-network physician wants to bill you $5,000 for a simple office visit, it’s his practice; he can do that even though it seems outrageous. However, an in-network provider has a contract with your health plan that spells out just exactly how much it can charge for its services. An in-network provider is not allowed to charge you more than the discounted rate your health plan has negotiated for those services.

Your health plan will pay a smaller portion of the bill for an out-of-network provider than it would pay for the same service provided in-network. In fact, some health plans won’t pay a dime for out-of-network care.

If your health plan does pay for out-of-network care, you might have 20% coinsurance for in-network services but 50% coinsurance for out-of-network services. Even with a 50% coinsurance, this doesn’t mean your health plan will pay 50% of the out-of-network bill. It will only pay 50% of the allowed amount. You’re stuck paying the other 50% of the allowed amount plus the entire portion of the bill in excess of the allowed amount. Learn more about this in “How To Calculate Your Costs for Out-Of-Network Care—Doing the Math.”

Worse yet, the out-of-network deductible is generally larger than the deductible for in-network care. Amounts you pay for out-of-network care don’t usually count toward your in-network deductible. Amounts you pay for out-of-network care don’t usually count toward your out-of-pocket maximum, either. Learn more about these issues in “What You Need to Know Before Getting Out-Of-Network Care” and “What Doesn’t Count Toward Your Out-Of-Pocket Limit?

How To Ensure You’re Using an In-Network Provider

There are three ways to make sure you’re using an in-network provider. Sometimes you have to use more than one. Sometimes just one will suffice.

  1. Check your health plan’s website.
  2. Call your health plan and ask. The number is probably on the back of your health insurance card.
  3. Ask your provider if it’s in-network with your health plan.

While checking your health plan’s website is often the easiest and fastest way to figure out which providers are in-network and which aren’t, my health plan’s website has a sneaky piece of fine print at the bottom of the listing of in-network providers. It says something to the effect of, “Although we strive to keep this list as accurate as possible, it may not reflect recent updates to our provider network. Always check with your provider to make sure it is still in-network.” For this reason, it’s wise to ask the provider before you get a service, even if you’ve already checked the provider’s status with your plan’s website.

Learn More

There are some situations in which your health plan might be willing to pay an out-of-network health care bill as though you had used an in-network provider. Learn more about these situations in “How To Get Your Health Plan to Pay In-Network Rates for Out-Of-Network Care.”

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