If you have ever received denial of payment for out-of-network services, you know how difficult insurance makes it for you to get care from an out-of-network provider.
Why? Out-of-network services are costly. There is no contract to define the maximum payment an insurance company would have to pay for an office visit, lab, procedure, or imaging test. It is harder to control the cost of your healthcare that way! Insurance companies make it hard for you to get out=of-network services by requiring prior authorization for even the most basic tests i.e. urinalysis or a blood chemistry test.
And guess what? Most, if not all, of the out-of-network cost will ultimately fall on you!
Out-of-network services are usually sought after for specialty care such as for cancer treatment and special surgeries, which are usually not done in the local community setting. Depending on the insurance plan, obtaining prior authorization for these out-of-network services is possible. If approved, your visits and treatments would generally be covered by your insurance. Just be mindful that processes to approve these services may be prolonged and thus delay your care.
To save money and to avoid unnecessary hassle with your insurance plan, you should try to find ways to utilize your in-network resources more fully by asking the right questions.
Some common scenarios where you may think about out-of-network services include:
- Surgery – For those who have gotten surgeries before, you know how important it is to find the best surgeon for the best outcome. So what happens if you find out your in-network surgeons cannot perform the needed surgery well? What options do you have?If you choose to go out-of-network, consider the costs you would have to pay out-of-pocket. These costs include: surgery, anesthesia, surgical center facility, postoperative visits, and sometimes even medications, particularly non-generic medications. These costs can add up rapidly and can easily become unaffordable.
To have insurance cover your out-of-network visit, you will have to see the in-network specialist first. Only if the specialist say that he or she did not have the expertise to treat your condition in the local community setting, you would have the chance to get approval (via prior authorization) for out-of-network services.
- Cancer treatment – Many cancer patients start to seek out-of-network care once standard treatments for their cancer do not work. They start to look for research / academic facilities for clinical trials and second opinions. Many network plans do allow you to go to academic centers in this scenario. But there are some networks that do not have these services, likely due to higher costs. Definitely speak with your provider or member services about how to have these visits to the academic center approved.
- Type of specialist not available locally– You may need to be referred to a specialist at a different county or at an academic center. These visits are generally approved by the insurance.
- Second opinion – There are times when you want a second opinion before pursuing surgery or receiving a medication. You usually can see another specialist in-network for evaluation and treatment. This is usually at no additional cost to you. Getting referral to an academic center is another option as well, but insurance plans usually limit the ability to go to academic centers due to cost.
Let’s also look at situations where you unknowingly saw an out-of-network provider:
- A new provider takes over the position of an established provider who has either left the medical practice or retired. While it is safe to assume that the new provider will enroll into your insurance plan, the credentialing / enrollment process can take between 6 and 12 months. Many patients have gotten billed for out-of-network charges due to this delay. Be careful!
- Your provider’s office decided to drop contract with the insurance plan. This tends to happen in the first 3 months of a fiscal year, when the contracted pay rate with the insurance company changes. Usually, the front desk or registration staff will inform you of this change.
- Your insurance company changes names. Name change happens usually when there is a company merger or the company gets bought out by another. When name changes happen, a lot of offices will not recognize your insurance and refuse to see you. In other times, the insurance plan may ask you to get an updated referral from your primary care provider using the new insurance. I recommend calling member services to obtain details about how to transition care when name change happens.
Conclusion:
I recommend making the most out of your in-network services for cost considerations. Out-of-network services can be covered when in-network providers are unable to treat your condition, but prior authorization is required. Asking to see another in-network provider or getting referred to an academic center are generally allowed under your insurance plan. And don’t ever be afraid to change insurance plans to fit your needs!