What Happens When My Healthcare Provider is Out of Network?

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healthcare provider with wooden blocks representing different medical specialties that may or may not be in network for healthcare plans.

 

When your healthcare provider does not accept your health insurance, it means they are not part of your insurance network. This can happen for several reasons. First, the provider might have decided to stop accepting your insurance provider. Or they are part of a healthcare system that failed to negotiate rates for care. Sometimes a provider will leave a practice that accepts your health insurance plan, and their new practice is not “in-network.”

This scenario is common and when you choose your plan, it may have included your preferred provider at the time, but over the course of the year, that plan and or that provider can change their policies. Healthcare providers and companies are moving pieces. Do not worry, AUI is here to help. Here are some things you need to know.

When a healthcare provider is not in-network you may experience the following issues:

Out-of-network costs:

If you receive medical services from a provider who does not accept your health insurance, you will be responsible for the full cost of the services. Out-of-network providers may charge higher fees compared to in-network providers. As a result, you may face higher out-of-pocket expenses.

Limits to your coverage:

Your health insurance plan may have limitations or exclusions for out-of-network services. In such cases, even if you receive care from a provider who does not accept your insurance, your insurance coverage may not apply or may only cover a portion of the costs.

Balance billing:

If your provider does not accept your health insurance but agrees to treat you, they may engage in balance billing. Balance billing occurs when the provider bills you for the difference between their usual charges and what your insurance plan covers. This practice can lead to unexpected and potentially significant medical expenses.

Seek an exception:

In certain cases, you may be able to request an exception from your insurance company to receive coverage for out-of-network care. For instance, if you are receiving pre-existing care for a long-term health problem. This typically requires demonstrating that no suitable in-network provider is available or that the out-of-network provider offers specialized care that is not available in-network.

Consider changing providers or insurance plans:

If your current provider does not accept your insurance and finding an alternative is challenging, you may need to consider switching either your provider or your health insurance plan. This will depend on your individual circumstances and the available options.

 What Are Your Options for Healthcare with Out-of-Network Providers?

Out of network written over a circle with a line through it over a healthcare cross representing a healthcare provider

We know it can be frustrating when something like this happens and your healthcare provider no longer accepts your health insurance. You do have options. Find in-network providers: Look for healthcare providers who are part of your insurance network. Most insurance companies provide online directories or customer service hotlines to help you find in-network providers.

Negotiate with the Provider:

You can try to negotiate with the out-of-network provider and discuss the possibility of a discounted rate or a payment plan. However, there is no guarantee that they will be willing to accommodate your request.

What is the Surprise Billing Act?

The No Surprises Act protects individuals who have coverage under a group or individual health plans from receiving surprise medical bills. This bill protects patients who seek emergency services and non-emergency services from out-of-network providers at in-network facilities. It also helps to prevent patients from receiving services from out-of-network providers such as ambulance and EMT service providers. It also establishes an independent dispute resolution process for payment disputes between healthcare plans and service providers. The No Surprise Act also helps with dispute resolution. Including the uninsured and self-paid individuals.  No matter what type of payment arrangement, the No Surprise Act will help anyone who receives a bill that is more expensive than the good faith estimate.

Beginning in 2022 the No Surprises Act offers new protections that prevent surprise medical bills. Individuals with health insurance now have new protections and bans on the most common types of surprise bills. Now everyone can request good faith estimates for medical services prior to receiving care. The goal is for individuals to know the cost of care up-front, prior to the service.

How Can AUI Help?

It is essential to review your health insurance policy and understand its terms, coverage limitations, and procedures for out-of-network care. Making an informed decision about your healthcare coverage is important. You need to explore all your options and the costs associated with coverage, premiums, network, and out-of-pocket expenses. Collaborating with a broker like AUI is always a great idea. We help you through the selection process and your broker is there for you throughout the year to help you get the most out of your health insurance plan. Do not go through this process alone. Call us or contact us today to learn more about how AUI can help.

 

We do more than cover small businesses and individuals with the right insurance policies and benefit plans – what motivates our team is helping you save more so you can invest more in your team, family, and goals.

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