Understanding "In-Network" and "Out-of-Network" Providers
February 08, 2023
When finding a provider to receive your health services, you've probably heard the terms "in-network" and "out-of-network" when it comes to your health plan. But what do these terms mean for a patient? And why should you be aware if a provider is out-of-network?
What does it mean when a provider is "in-network" with a health plan?
A provider is a person or facility that provides healthcare. When a provider is in-network it means there is a contractual agreement with that health plan regarding the rates for services. The provider will accept negotiated rates for services from the insurance. This means a patient will typically pay less for medical services received and is less likely to receive surprise bills.
What does it mean when a provider is "out-of-network" with a health plan?
Providers that are out-of-network are those that do not participate in that health plan's network. The provider is not contracted with the health insurance plan to accepted negotiated rates. This mean that patients will typically pay more or the full amount for the service they receive.
Why should patients see in-network providers?
Seeing an in-network provider for medical services can significantly reduce your medical expenses. Remember that in-network providers have a contractual agreement for negotiated rates with the health plan, so they cannot charge you more than that negotiated rate for a service. Seeing an in-network provider will always ensure any costs you do incur (copays or co-insurance) are applied to your health plan's deductible and out-of-pocket maximum (out-of-network costs don't apply to these amounts). To find the amounts you will pay for specific services, you can check your health insurance plan's Summary of Benefits.
What is the best way to find which providers are in-network with a patient's health plan?
Most health insurance companies offer multiple ways to find if a provider is in-network. To find the most accurate benefit information from your health plan, you can:
- Call their Customer Service department
- Check their website for their online provider directories
- If offered, check your online member portal.
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