Whether you’ve had the same health insurance company for years or switched to a new health insurance company, you may notice that the amount of money that you pay out of pocket varies from one healthcare provider to another. In most cases, this variance in cost is directly related to whether a healthcare provider is within your health insurance company’s network (if you have a PPO), if you have a deductible to satisfy first, or if you have a co-pay.

To get the most from your health insurance, it’s important to be informed whenever you’re seeking out a new healthcare provider. To help control costs, your health insurance company has a list of in-network providers. However, accepting your health insurance and being “in-network” aren’t necessarily the same thing. By ensuring that you select a healthcare provider that is in your health insurance company’s network, you can save a significant amount of money. If you have an HMO, you’ll be required to go to your primary doctor first, and there will be no out of network benefits except in emergencies.​

What Does It Mean to Be In-Network?

This refers to the groups of doctors, hospitals, and other medical professionals, to provide discounted healthcare services to its customers. The insurance company and the medical provider have contracted, to pay a certain amount for specific procedures to the medical provider, and the medical provider has agreed to accept that specific amount and not charge more.

The cost of healthcare seems to go up every year. Individuals and health insurance companies strive to bring down the cost of care. To minimize the expense and ensure that they’re providing customers with competitive rates, health insurance companies negotiate with providers for lower rates on healthcare services. In-network providers, also known as participating providers, are those who have contracted with your health insurance company to accept negotiated rates for the services that they provide.

Negotiated rates are lower than the provider would charge for a given service to someone who did not have health insurance coverage.

To provide an incentive for receiving healthcare services with an in-network provider, health insurance companies may pay a greater portion of the cost of a service received. For that reason, you will typically pay less out of pocket when you go to an in-network provider. Again, if your plan is an HMO or EPO, you are required to stay in the network, and they will not offer any out of network benefits.

If you have a PPO, POS, EPO or HMO health insurance plan, then your health insurance company will have a list of in-network providers.

What Does It Mean to Be Out of Network?

This term typically refers to any doctors, hospitals or other healthcare providers considered to be non-participants by your insurance plan (HMO, POS, or PPO). Depending on your plans guidelines, services provided by out-of-plan providers may not be covered, or only covered in part.

A hospital or other medical provider that has not contracted with your health insurance company to accept discounted rates is said to be out of network. Your health insurance company may cover a certain amount (small percentage) of the cost for services you receive from an out-of-network provider using a PPO, but you’ll pay more for being out of the network. Sometimes the insurance company will pay what’s called “usual or customary” and if not, you will be responsible for the entire out of network portion of the bill.

It’s important to note that while a hospital or doctor’s office may accept your health insurance plan, especially if you’re a customer of a large insurer like BlueCross BlueShield or UnitedHealthcare, that doesn’t necessarily mean that they are an in-network provider. To ensure that you’re getting the best price for medical care, you should consult your health insurance company’s list of preferred “contracted” providers, which is usually found on their website. When you create an account online through your health insurance providers website, your individualized portal will typically have the doctors and providers you can go to.

While it seems like hospitals and medical practices would be strongly motivated to accept a health insurance company’s negotiated rates, after all they’re almost guaranteed more business from that insurer’s customers, it’s not uncommon for providers to reject these lower rates. In most cases, this is a result of lower reimbursement (payment to doctors), meaning that the fees that are approved by the health insurance company are not enough to cover the cost of providing quality care, or not as much as the providers are needing/wanting.

Find a Health Insurance Plan With Nevada Insurance Enrollment

Choosing a healthcare provider can be a daunting task, especially if you or anyone in your family have health conditions to take into consideration. Fortunately, you don’t have to take on this task alone. One of our licensed health insurance agents can help you compare different health insurance plans and determine whether your preferred healthcare provider is in a health insurance company’s network.