In Network Providers

What’s an In Network Provider

Provider networks are made up of healthcare providers contracted by the insurance to offer care to subscribers.

Physicians, other healthcare providers across different specialties, pharmacies, and other contracted facilities are the “in-network” providers.

When subscribers visit a provider who is in-network, they are using a provider who participates in your health insurers’ provider networks.

Insurance providers usually have a separate list of network providers for different health plans. Some plans only cover in-network, while other plans offer both in-network and out-of-network care.

Some plans require their members to pay more or may need the member to get express permission/referral if getting care from a provider who is not in the plan’s network.

Plans that require members to use in-networks include:

• Preferred Provider Organizations (PPOs):

The plan’s network will charge less for accessing care. Members can access physicians, hospitals, and providers outside of the plan’s network without any referral but for a higher fee compared to the plan’s network.

• Point-of-Service (POS) Plans:

They are the same as PPOs. You pay less for using healthcare providers on the plan’s network.

However, you must get referrals from your Primary Care Physician (PCP) to access specialists.

• Health Maintenance Organizations (HMOs):

HMO strictly restricts care to participating Physicians. The only exception to this rule (access to out-of-network care) is during emergencies. HMOs usually limit the service area eligible for coverage. Subscribers usually have to be within that range to get care.

• Exclusive Provider Organizations (EPOs):

The cover is only available if you use physicians, specialists, or hospitals within the plan’s network. The only exception to this rule is during emergencies.

If the plan covers out-of-network care, it’s considered wise to stay in-network as it greatly reduces the bill payable for health care.

What does Out of Network Provider mean

With an Out-of-network, your PCP or doctor is not contracted with your health insurance plan provider.

Some plans may allow its subscriber to access Out-of-network but at a steep price. However, some health plans, like the HMO plan, strictly do not allow Out-of-network care except in cases of emergencies.

Difference between In Network and Out of Network

Cost

The out-of-pocket charges for out-of-network health care are significantly higher when compared to care in-network.

The contract between the participating providers and the insurance sets the payment (usually at a discount) for the services they provide. This will be significantly less compared to services received out-of-network.

The subscriber is responsible for the differences in cost between the set prices and what the out-of-network provider is charging.

Care

In-network care can only be provided by participating providers, usually provided as a list. Out-of-care services can be provided by any doctor or physician not contracted by the insurer.

Most insurers have lookup tools on their website to help in the search. All a subscriber needs is to enter their location and health plan, and it will return results showing only providers in their network.

Benefits

Within the insurer’s network, subscribers have access to the largest network of physicians and hospitals within certain regions. Some insurers have as many as 50,000 doctors and 200 hospitals across America. This provides the comfort of knowing you can access the best quality standard available out there.

Always ensure you check the benefits of the plan before picking a physician or other health care provider.

Why does in network covers certain services and not other

• Preapproval:

Most plans require preapproval or prior authorization for certain procedures, treatments or hospital admission.

The provider is required to seek approval from the insurer before performing certain services. If approval is not sought, and permission not granted, the insurer will decline to cover the service.

• Design of the Plan:

Some health plans like HMOs were designed around in-network doctors and facilities.

These participating providers were contracted and are to be paid an agreed-upon price for specific services. To save cost, these contracts usually do not cover all components of certain procedures e.g. anesthesiologists may not be covered during certain surgical procedures.

The services you are requesting should be fully covered by your insurance. Also, ensure all tests are only done in-network or in preferred labs.

• Prescription drug costs:

The access to certain first-class drugs (tier 1 to tier 3 sometimes all the way to tier 4) depends on a plan’s formulary. You can find this information on the insurer’s website.

Most plans offer generic versions of certain drugs. Always seek preapproval if in need of first-class drugs or some specialty drugs.

The plan may cover a portion of the cost of the first-class drugs toward your total deductible (copay accumulator adjustment programs).

Bottom line

Please;

• Use network providers to lower out-of-pocket costs and reduces unnecessary high consumption of your cover limit. Don’t spend more if you don’t need to!
• Out-of-network providers do not offer negotiated discounted fees. Expect higher fees compared to your health insurance carrier. Insurance expects the subscriber to foot the difference (balance billing). The insurer will not cover the increased cost!

• Always ensure to make full use of the provider lookup tools on the insurer’s website to confirm if the physicians you want to visit are in or out of network.

Many states have formulated laws that require plans to offer cover for out-of-network services at in-network rates. Should there a need arise to go out of network, always check with the insurer and ensure to follow the rules pertaining to your state and plan.