Selecting a medical insurance plan can be confusing, and then finding a doctor or medical service provider is often stressful. Because if both are not chosen correctly, you may end up paying for medical expenses out of pocket. This article will explain the importance of selecting wisely and identify the risks of not using an in-network provider.
When a doctor’s appointment or medical service is billed to insurance, the insurance company checks if the service was performed by an approved provider, and it sets a reasonable fee for the service. Then the fee will either apply to deductible meaning the patient is expected to pay for the service, or if the deductible has been met, then insurance will pay a percentage, leaving a copay for the patient.
With changes in medical insurance over the last few years, this means many plans have high deductibles both for in-network and especially for out-of-network providers. Some plans have out-of-network deductibles as high as $10,000, or they may have no coverage at all.
With an in-network provider, deductibles are usually lower and the provider has to agree to the fee the insurance sets. You can estimate your cost by finding out the fee for the service, the coverage (%) your insurance will pay, and your remaining deductible. Learn how to calculate your cost in this article on insurance coverage and deductibles.
With an out-of-network provider, patients are often left paying out of pocket because:
- The insurance plan has no out of network coverage,
- The out of network deductible is very high and has to be met before insurance pays, OR
- The insurance’s fee is less than the provider charges so they charge the different to the patient
Here are a couple examples of when patients get surprised with large costs.
Scenario 1 – HMO Insurance: You sign up for a local HMO insurance plan because the monthly fees are lower. You check to make sure that your doctor is part of their network, so your doctor visits are covered and you only have a small co-pay, which is great. Your doctor orders lab work to test for a possible condition, and sends it to large national lab company. The lab is not a local provider, so it is not part of your insurance network. You have a $5000 out-of-network deductible, so you receive a bill for $300 of lab fees because it applied to your deductible.
Scenario 2 – Specialist: You sign up for a PPO plan with great coverage and a large network of providers. Your friend tells you about a specialist, such as a dentist that makes oral appliances to treat sleep apnea. The dentist is a specialist and has contracted with a few insurances but is not part of your plan. You have an out-of-network deductible of $1000, but you decide that the treatment is worth that, so you agree. The specialist bills your insurance, and $1000 is applied to deductible. However, the dentist charges $2000 for the service, so you receive a bill for $2000. Since, the dentist is not a contracted provider with your insurance, the reasonable rate set by the insurance doesn’t apply, and you are responsible for the full service charge.
Both of these situations could be avoided by selecting an insurance plan with a large national network of providers and going to physicians, labs, and specialists contracted with your insurance. Ask questions before you agree to a service. Ask providers to confirm they are in-network and for an estimate of your cost. Ask your insurance company if the provider or lab you plan to use is in-network and what the rate is for the service. You are your own best advocate!
Millennium Sleep Lab is proud to be an in-network provider with all major insurances for home sleep tests to diagnose obstructive sleep apnea (OSA). We accept insurance companies’ reasonable rates and strive to provide quality service with gold-standard equipment and personal training in the comfort of home.
Medical insurance can be confusing, but with a little research you can find the best healthcare insurance for your situation and in-network providers like Millennium. Don’t let the confusing processes and terminology discourage you from getting the care you need with as little out-of-pocket cost as possible!