Skip To Main Content
Health Insurance Basics

The Perils of Seeing a Doctor Not in Your Plan

June 22, 2017

Everyone today is concerned with rising health care costs. Here’s one way to make sure you get the best value out of your health plan: use doctors in your health plan’s network. You’re likely to save money. These doctors have an agreement on how much they can charge you – and that protects you from being charged at a higher rate – sometimes much higher.

Infographic Text

You woke up feeling under the weather today. You paid your insurance bill, so you picked a doctor and made an appointment. A week later you received a hefty bill in the mail. What went wrong? You may have gone to a doctor who doesn’t participate in your plan.

Doctor in Your Plan vs. Doctor not in Your Plan
  • Doctors in your plan have an agreement on how much they can charge when you see them, so there shouldn’t be any surprises.
  • Doctors outside your plan have no agreement, so they can charge any price they want. Then, you have to foot the bill.
How Hospital Bills Work

Let’s say you have cataracts and need surgery. Here’s how your bill from the doctor who’s in your plan will look versus the one from the doctor not in your plan.

The usual rate for cataract surgery is $600, which is the amount your benefits cover.

Doctor in Your Plan
  • Your doctor charges $1000.
  • You are charged 20 percent of the cost of the usual rate ($600), or $120. This percentage of the cost is also called coinsurance. The percentage often differs among plans and services.
  • Because your doctor and your health plan provider have an agreement, you are NOT responsible for the $400 difference between your doctor’s fee and the usual rate.
  • Total bill: $120
Doctor Not in Your Plan
  • Your doctor charges $1000.
  • You are charged 40 percent of the cost of the usual rate ($600), or $240. That’s because the percentage of the cost you pay to see a doctor outside of your plan is 40%.
  • You will owe $240 plus the $400 difference between your doctor’s fee and the usual rate.
  • Total bill: $640

Note: Federal law prohibits health plans from charging more for emergency care that’s not in your plan. However, you may be responsible to pay more if you’re admitted to a hospital that’s not in your plan.

You can avoid hidden fees by using the Find a doctor tool on your plan’s website –before your visit – to make sure your doctor participates in your plan.

Sources:
https://www.anthem.com/wps/portal/ahpemployer?content_path=employer/va/f5/s1/t0/pw_034761.htm&state=va&label=Choosing+Doctors,+Hospitals+and+Other+Health+Care+Professionals

http://khn.org/news/beware-of-higher-charges-if-you-go-to-an-out-of-network-emergency-room/

http://www.nhpf.org/uploads/Handouts/Kyanko-slides_12-06-13.pdf