The Insurance Solutions Experts®
Why is it important to go to an in-network physician?
By: Jona Baldwin
Although lots of insurance plans do cover out of network doctors, it is still better to consider in network when possible. Here’s why:
An in-network doctor under your plan means that a contract has been signed between the insurance company and the doctor you are seeing. The insurance company has agreed to pay a certain amount for services for each procedure code the doctor is licensed to perform. By signing this contract, the doctor agrees to not ‘balance bill’ a patient meaning, they cannot send a patient a bill for the difference of what insurance pays and what they would like to charge for that particular code. Outside of your copay, deductible and coinsurance, you are not obligated to pay additional fees for seeing this doctor.
When seeing an out of network doctor, this means that the doctor and insurance company have no contract. This also means that this doctor can charge any amount he feels appropriate for each procedure code he sees patients for, whether this be an office visit/consultation or surgery. Although your insurance plan may have a percentage (your coinsurance), that they pay for this doctor, it is a much smaller amount. If you see ‘80/20’ for instance for an out of network doctor, this does not mean that your insurance will pay 80% of this doctor’s fees. What this means is that they will pay 80% of what they have deemed ‘reasonable and customary’, after you have met your deductible of course. The difference between the percentage paid for the allowable amount and the amount the doctor charges is your responsibility.
Reasonable and customary amounts, sometimes also called ‘allowable amounts’, are the amounts paid by insurance per geographical area for medical services. This amount is determined based upon what other doctors in that area charge per service. Often times, these amounts are low.
In conclusion, seeing an in-network doctor when possible is always the most effective way to make sure you are protecting yourself from more out of pocket expenses than you planned for. In-network providers can be found on your carrier’s website by using their provided links to search doctors, clinics, and hospitals or, your agent can assist you before choosing your plan.