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In-Network Vs Out-of-Network Providers: What is the difference?

Seven Corners Insurance

In-network vs. out-of-network providers

When you are exploring different health insurance plans, you may stumble upon terms like ‘in-network’ and ‘out-of-network’. Do you know what these terms mean? If you want to save more on medical bills, you need to understand how in-network and out-network providers’ work.

A health insurance network consists of a group of medical care providers, hospitals, doctors, and Urgent Care’s and multiple specialists that offer health care services to policyholders of a visitor health insurance plan at a negotiated rate.

What is in-network?

Your insurance company has a contract with providers like specialists, doctors, , facilities, hospitals, and more and sets negotiated rates with them for their services. When you see a doctor within the provider network, you are in-network. Depending on the plan, your deductible,  and coinsurance may be waived for using network providers, for an eligible illness/injury. . By using in-network providers you get a  hassle-free experience and receive discounted rates for the treatment received.

What is out-of-network?

When you choose doctors, clinics, and specialists outside the list of providers, you go ‘out-of-network’. This means that your insurance plan provider has no contract with the doctor or specialist, resulting in no discounted prices. With out-of-network providers you pay higher prices, there is no direct billing  and there could be a lack of understanding from the provider’s office.

Most of the comprehensive visitor insurance plans  can cover both in-network and out-of-network medical care. Even if your insurance plan covers out-of-network, you will pay more than an in-network cover. The limited benefits visitor insurance plans may follow a network but do not have negotiated rates.

In-network Vs. Out-of-network cost

In out-of-network, you can end up paying more, for a covered illness or injury. In case of serious illness or injury, you may be paying thousands of dollars for the care and treatment. Most plans cover you for an eligible illness/injury, out-of network as well, however you do not get negotiated rates and you will have to meet your deductible and co-insurance. But for the eligible illness/injury when you choose a provider from your plan’s network, depending on the plan the deductible and co-insurance can be waived and and then the rest up to your policy maximum may be covered by your insurance provider.

FAQs

How should you find the hospitals?

You can call your insurance provider and speak to their representative to find out about the names of the providers. Or you can check your ID card because it may have a website or a number to access the information. Or you can call the hospital or clinic directly to find out if it falls within your plan’s network.

Do in-network and out-of-network providers change?

Healthcare professionals and care providers may change over time between networks.  Hence, you need to regularly check and confirm that no changes are introduced within the system to avoid unexpected out-of-pocket medical bills.

Now, if the in-network doctor refers you to a specialist out-of-network, make sure that your new healthcare professional is included in your coverage. If you find out that your healthcare professional who was in-network and is now out-of-network, you may choose to visit him/her or consider switching health care professionals to an in-network provider.

Do you need to select a primary care provider before the coverage begins?

For visitor insurance plans, you do not have to select a primary care provider. If the plan you opted for has a network, you can go to any in-network provider in the event of an injury/illness

Are you covered outside of the service area and country?

Visitor insurance plans cover you outside your country of residence or country of citizenship. A comprehensive plan typically will have a PPO network in the US. Outside the US you are free to go to any provider in the area. Some plans do have a list of international providers.

Can you go to any health care provider while traveling?

In the US, you can search for in-network providers with the zip code you are travelling in. The documents you receive after completing the purchase of the visitor insurance will contain details of the PPO network. You can simply click on that link and search for providers in the area.

If at all there is an emergency and you do not have access to the PPO providers, you can get treatment from any provider. The visitor insurance plans offer coverage for out-of-network eligible illnesses and injuries as well. The only difference is you will not get negotiated rates and will have to pay a higher co-insurance.

Can you see an out-of-network provider?

Yes, you can  visit an out-of-network provider, but you must meet the deductible and coinsurance. The expenses of visiting an out-of-network provider will always be higher than going to an in-network provider. There is no fixed rule that you must see an in-network provider but if you do, you get the benefit by getting negotiated rates, cash less billing, and coinsurance and deductible waived for an eligible illness/injury.

What will you pay for an out-of-network provider?

If you see a provider out-of-network, you may have to pay more. You will have to meet your deductible and a higher co-insurance.As you will not get the negotiated rates, depending on the treatment you might reach the covered amount on your plan very easily. ,  For a Limited benefit visitor insurance, as there are no negotiated rates for using the in-network providers, it will not make a difference on using in-network or out-of-network providers.The insurer will pay the provider the allowed amount for the covered services. You will be responsible for paying the difference between the bill charged and the amount paid.

How do you pay for out-of-network services?

This will depend on the provider on how they are set up for billing. They can bill the insurance company directly, and submit  the claims. If the provider does not bill the insurance company directly, the insured will be responsible for paying upfront and then getting reimbursed for the claims from the insurance company. However, note that prescriptions are always out-of-network. You need to pay for prescriptions and then submit the amount for reimbursement.

For the claims to be settled, you need to complete the claim form. The insurance company’s claim department will assess your claims and reimburse you the amount that you paid for the medical services after meeting your deductible and coinsurance.

Buying a plan is completely your choice, hence it is often up to you whether you opt for in-network or out-of-network providers in your visitor insurance plans.  This may appear confusing to some, which is why you get us, Visitor Guard®. We are a certified insurance company , operating in the US and helping people globally to choose the right travel insurance plan. Call us now and get your queries resolved!


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