What's the Difference Between In-Network and Out-of-Network?

by Team eLocal
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Having adequate healthcare insurance is essential, but it's also important to understand where you can receive treatment without high out-of-pocket costs.

Depending on your plan, you may need to use an in-network provider to access the most affordable treatment prices.

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What Is an In-Network Provider?

Healthcare insurance companies have a network of doctors, hospitals and other healthcare providers that accept their plans. Insurers call these providers in-network providers or participating providers.

Insurers also set an approved amount for all treatments and services included in their policies. An in-network provider agrees to accept the insurer's agreed amount for covered services when they join the network. Therefore, you won't pay more than the approved amount for any treatment or services you receive through an in-network provider.

What Is an Out-of-Network Provider?

An out-of-network provider is a doctor, hospital or another provider that doesn't accept your insurer's plans. Therefore, you won't necessarily receive treatment and services for the approved price provided by your insurer.

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Is There a Price Difference With Out-of-Network Providers?

Choosing an in-network provider is usually cheaper because your insurer's approved amount will generally be less than what you'd pay without insurance. Some healthcare insurance plans exclude treatment from out-of-network providers altogether, which means you'll pay all the costs out of pocket.

Other plans may use a practice known as balance billing if you use an out-of-network provider. Balance billing means that your insurer pays the approved amount, and you pay the difference. For example, you would only pay $20 for a service costing $100 from an out-of-network provider if the approved amount is $80.

Most policies cover emergency treatment and services received through an out-of-network provider. Therefore, you can usually go to your nearest hospital in an emergency, even if it doesn't accept your plan. You won't typically need to pay the price difference between the cost of your care and your insurer's approved amount. However, it's worth checking how your insurer bills out-of-network emergency care when choosing a plan and picking one that covers all providers if you need urgent medical help.

How Do I Find In-Network Providers?

Your insurer can provide a list of in-network providers in your area, and many have website tools that allow beneficiaries to locate their nearest suitable in-network doctor or hospital. Alternatively, you can contact a provider directly to ask if they accept your plan.

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