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Health Insurance Basics

What’s the Difference Between In-Network and Out-of-Network Doctors?

July 29, 2017

One of the many valuable benefits of your health plan is its list, or network, of preselected health care professionals. The doctors, hospitals, pharmacies, labs, and other health care providers in your plan's network have partnered with your plan to offer you the best possible rates they can for your healthcare.

Using doctors and other health care professionals in your plan generally means your care will be more affordable--you won't end up paying more than you should.

Doctors in your plan are often called in-network providers, participating providers or preferred providers.

What Is an Out-of-network Doctor?

They are doctors who haven't partnered with your plan and might not offer you the most affordable costs.

Providers outside your plan can charge you as much as they want and may not accept the usual amount you're responsible for through your plan as payment in full.

Charging you for amounts in addition to your insurer's contribution, plus your copay or coinsurance is known as "balance billing." This practice can prove costly for you if you use doctors outside your plan.

Another disadvantage is that doctors outside your plan may not help you request preapprovals when they're customary or file benefits claims for you.

Staying In Your Plan Saves You Money

Suppose you visit a doctor and his or her fee for services is $250. Here’s how your costs may break down, depending on whether the doctor was in your plan or not.

If the doctor is in your plan, you and your insurer would pay your portions of your doctor's negotiated rate. If that rate was, for example, $175 and your copay was $35, you'd pay $35 and your plan would pay $140.

If the doctor was outside your plan, your plan would still pay the same $140, but you'd be responsible for your $35 copay, plus the additional $75. Instead of just $35, you'd pay $110.

Going Outside Your Plan Can Be Costly

Some healthcare plans only cover services from doctors in the plan. If you have this type of coverage, you are usually financially responsible for the costs incurred from any doctor or health care provider not in the plan.

Other plans cover services for both in-plan and out-of-plan providers, but the amount they pay may be different. In these cases, doctors in your plan will typically be less expensive for you.

Which Providers Are In-network

Doctors who say they "accept" your coverage aren't necessarily in your plan. To find out if a provider is truly in your plan, call customer service and ask. You can also search your plan’s online directory or look at your insurer’s printed list of plan doctors.