What’s the Difference Between an In-Network and Out-of-Network Provider?

When a doctor, hospital, or other provider accepts your health insurance plan, they are considered “in network” or “participating” providers. On the flip side, doctors or providers who don’t take your plan are considered “out of network.” In-network health care providers have contracted with your insurance company to accept certain negotiated (discounted) rates and, as a result, in-network doctors and facilities will not charge you more than the agreed-upon cost. Out-of-network providers, however, have not agreed to the discounted rates, and can charge you full price for services.

In-Network Savings

When a provider joins a network, they agree to accept the insurance carriers approved amount for their services. For example, a doctor may charge $150 for a service. Your insurance company’s approved amount is $90. Your savings is $60. On your claims and explanation of benefits statements (EOB), you will see these savings listed.

Doctors or hospitals who are not in the network will not accept the approved amount. Your share of costs is different, and usually higher, and you will be responsible for paying the difference between the provider’s full charge and your plan’s approved amount. That’s called balance billing.

PPO plans include out-of-network benefits, which help to pay for care you get from providers who don’t take your plan, though the cost is usually higher than using an in-network provider. For example, your plan may pay 80 percent and you pay 20 percent if you go to an in-network provider. Out of network, your plan may pay 60 percent and you pay 40 percent.

How to Find In-Network Providers

The “Find a Doctor” feature on your insurance company’s website will show you in-network providers. You can also call your insurance company’s Member Services Department—the phone number can be found on the back of your ID card.

Before you go to a doctor or hospital, it is always a good idea to call and ask if they take your plan. Sometimes the insurance company isn’t notified right away when things change.

Plans vary and you can avoid unexpected medical bills by knowing how your plan works. Certain choices you make can affect what you’ll pay out of pocket. Knowing the difference between in-network and out-of-network care can help you save on health care expenses.

Your ARC representative is available to help you find in-network providers. Contact us today and we can walk you through the steps so you get the best savings on your health care.