Making the Most of In-Network Options: A Guide

If the pandemic has taught us anything, it’s the importance of having access to quality healthcare. Everyone’s health journey is unique, but the best way to take control of it is to know your options. This includes learning how to navigate your health insurance and identifying in-network vs. out-of-network providers. 

In practical terms, health insurance companies cover most healthcare costs for in-network providers. But what is a health insurance network? It’s a group of labs, doctors, hospitals, or clinics that work with the health insurance company. TLDR: It’s less expensive to use providers covered by your health insurance. 

If you venture out of your network, you might face unexpected medical expenses. Surprise medical bills are a huge issue for more than 50% of patients, and the average surprise bill costs more than $600. Plus, 1 in 5 patients who go in for elective procedures get stung by unexpected out-of-network bills. 

In-Network vs. Out-of-Network Realities 

Generally speaking, it’s financially better to stay in your insurance network. That’s because in-network providers agree not to bill consumers more than the amount agreed upon between the health plan and the provider, which protects against balance billing. Provider networks also allow plans to select providers based on certain standards. This ensures access to effective care and is the exact reason why health insurance companies use provider networks. 

Let’s look at in-network vs. out-of-network plans in action. Suppose you go to an in-network doctor, and the total charge is $250. The health insurance company has negotiated a $75 discount with your provider, plus it covers $140. In this case, all you would have to pay is the remaining $35. If you opt for out-of-network care, your insurance would still cover $140, but you’d be on the hook for the remaining balance of $110. 

So what happens if you’re in a situation that requires out-of-network emergency care? It would likely be cheaper to switch to a doctor in your network, but you can always ask about your options if you’d prefer to stay with your current doctor. Patients can sometimes pay the cash price, but this won’t count toward your insurance deductible or out-of-pocket maximum. You can also ask your health insurer for a network gap extension, which treats the provider as if it were in the network — note that this usually only applies if no other doctor in the area practices the specialty you need.

What if your provider suddenly falls outside of your network? That’s where preferred provider organization (PPO) plans come in. How do PPO plans work? A PPO plan lets patients see out-of-network doctors when their health insurance changes, but they have to pay a little bit extra. You can also opt for a point of service (POS) plan, which will have the insurance company cover the costs as long as you receive a referral to an out-of-network provider from an in-network doctor. Lastly, you could ask your doctor about paying in cash to see whether they offer a discount for cash payments. 

Tips for Working With In-Network Providers 

Choosing your health insurance plan is one of the most important decisions you can make, but it isn’t always easy. Here are a few ways to save money and alleviate stress when seeking in-network care: 

1. Check your insurance company’s website. 

Most insurance companies have a listing of in-network providers on their websites. Many customers still find these listings confusing or outdated, so Health Karma created the most extensive directory of medical physicians to help users find in-plan providers. You can filter by location, rating, specialty, network, gender, language, and more to find the doctor that’s right for you. 

2. Double-check with your provider. 

Before you schedule an appointment, call your provider to make sure they are in your insurance network. Ask something straightforward like, “Do you take [insert plan name here]?” Give them your plan number and member number just to be safe. 

3. Inquire about connected facilities. 

Doctors treat patients out of many different facilities. Save money by ensuring your health insurance plan covers their hospital, emergency room, surgery center, imaging facility, or lab. It’s easy to assume your plan treats all of these equally, but that isn’t always the case. 

4. Ask elective procedure doctors about in-network services. 

If you’re undergoing elective surgery, you’ll likely be treated by several professionals, some of whom could be outside of your network. For example, anesthesiologists notoriously are outside of insurance networks — and they bill that way. Talk to an administrator before your procedure about in-network services. While they won’t guarantee all in-network services, you’ll at least be on the record. 

It may be necessary to get care outside of your network sometimes, but your best bet is staying in your network to save money and ensure top-notch healthcare. Surprise medical bills are the last thing you want to worry about when you’re facing a health issue. Knowledge truly is power — and a little bit of research can improve both your physical and financial health. 

Interested in finding a healthcare provider who’s in your insurance network? Search for providers both by specialty and based on your insurance coverage through Health Karma.