To keep your health care spending in check, when seeing a new doctor or if you are referred to a specialist, you should always check your health plan to make sure the new doctor is in the plan's network.
If you don't and the doctor is out of network, you could be left paying for substantial costs since you strayed from your network. Insurers are able to offer the rates they do because they contract with various doctor and hospital networks. They negotiate lower rates with those networks in exchange for sending their insureds to them for treatment.
But if you choose a physician out of the network, those same rates do not apply and the insurer will require you to foot most of the bill.
Seeing an out-of-network provider means that you as the policyholder must pay the difference between the provider's regular fees and what your insurer covers on a reimbursement schedule.
There are some exceptions for emergency care. Your insurance company pays the rate it normally would pay for policyholders seeing out-of-network doctors. In addition to this, the company pays amounts that comply with federal regulations.
After your insurance company pays the amount it has already agreed to, the rest of the balance will still be outstanding and must be paid out of pocket.
Your insurance company works with a wide network of health care professionals. With access to physicians, specialists, hospitals and clinics, there is no need to take a chance by visiting an out-of-network provider.
Lab work and other tests are also covered and performed by several network providers. Having lab work done by an out-of-network provider can easily reach into the thousands, so again, just like with doctors, make sure you check that the lab is also in your network.
Just a CT scan or MRI will also cost more than most people can afford upfront.
Urgent care facilities
Your insurance company can help find local providers for the quickest service possible. In some cases though, it may be necessary to wait for an appointment or referral.
That said, insurers typically work with urgent care facilities. When there is not a medical emergency but an issue that requires prompt attention, ask about an urgent care facility that is included in the network. This cuts down on the need to wait in long lines at an ER and ensures health needs are met in a timely manner.
Your insurance company can help in finding a regular physician for new patients.
A primary care provider is responsible for overseeing regular medical appointments and can provide referrals for other services.
The takeaway
Every policyholder should make a point of understanding their policy thoroughly and what is covered. It is also important to review a list of providers and services. You should be able to check if a physician is in your health plan's network on your health insurer's website. If you are unsure, you can contact your health plan directly.
To learn more about a personal health plan and for questions about making any changes, call us.