One of the most valuable things about health insurance is that it can pay for a majority of our medical bills. Many of today’s health insurance plans utilize “provider networks”, which are essentially lists of doctors or hospitals who have a contract with insurance companies to provide medical services.

If you’re shopping for health insurance, it’s important to know what provider networks are and how to use them, so you can get most from your health insurance dollars. Continue reading to find out more about how provider networks work and how an out-of-network provider could end up costing you thousands. 

Why should you care about provider networks?

The answer is simple: Money. Receiving medical care from an out-of-network doctor or hospital can cost you hundreds or potentially even thousands of dollars more than seeing an in-network doctor or hospital. In an eHealth survey of more than 6,500 customers, at least 1-in-5 of those who received medical care saw an out-of-network doctor. On average, these people spent nearly $900 more on their care than those who paid out of pocket for care from network doctors.

What are medical provider networks?

A provider network is a group of doctors or hospitals that enters into a contract with a health insurance company. Most doctors and hospitals have network contracts with more than one insurance company. Doctors and hospitals like provider networks because they help guarantee a steady stream of patients. In return, they agree to offer the insurance company’s members a reduced price for the medical care they receive.

In-network provider

What is an in-network provider or network doctor? An in-network provider is a professional entity, such as a healthcare provider, medical facility, pharmacy, or supplier, that is contracted with an insurance company to provide services to its members. The network negotiates a price with various entities so that the patient only pays a portion of that cost, and the insurance company writes off the remainder of the bill. These insurance networks will then provide services to the policyholders on behalf of the insurance company at lower prices. Due to the structure of in-network insurance companies, many providers are strict about only covering visits to a network doctor. However, other organizations will allow a claim to be submitted for at least a partial reimbursement if the patient uses an out-of-network service. 

Out of network provider

An out-of-network provider is a service provider that exists beyond the scope of an insurance plan such as HMO, EPO, or PPO. In some cases, an insurance company will allow a patient to select the doctor and health facilities of their choosing, while other networks may only cover in-network services, or will pay only in the case of an emergency. Therefore, it is possible to be stuck with the full cost of any treatment received outside of a network, making it crucial to study the terms of the agreement and find out what you will be responsible for paying.

What do provider networks mean for you?

Having access to a provider network through your insurance plan is kind of like knowing a secret handshake or being part of a special club. It gives you a list of doctors and hospitals that are willing to see you at discounted prices for care. Let’s look at an example to illustrate the concept. This is just an example, of course. The real dollar figures involved may vary. 

Say your local doctor generally charges $250 for an office visit. That’s what you would pay if you just walked in off the street without health insurance. If you’re insured and the doctor is part of your provider network, however, you may only be charged $120 for that visit. Depending on how your insurance plan works, some part of that $120 may be paid by you and some part may be paid by the insurance company – but once a total of $120 is received, the network doctor will consider your bill paid in full.

What happens if you see someone outside your network?

Getting medical care from a doctor, lab, or hospital outside of your insurance company’s provider network can cost you a lot of money. In the example given above, seeing this doctor without the benefit of a network relationship could mean that you’re on the hook for the full $250! Even if you have coverage, your insurance company may not contribute anything toward care rendered by providers outside their network.

What if my doctor refers me to a non-network specialist?

This is a common question. Is a non-network specialist automatically covered by your insurance company because you were referred to the specialist by an in-network doctor? The answer is no. In the end it’s up to you – not your doctor – to make sure that any specialists you see or hospitals you visit are in your insurance company’s network. Luckily, most insurance companies have great online resources to help you find doctors and hospitals that are in your network. They can also confirm the network status of any doctor or specialist you might like to see. Remember, insurance companies regularly change which doctors, specialists, and hospitals are in their network, so make sure you get the most current information.

What happens if I visit an out-of-network emergency room?

Most health insurance plans make some exceptions for network rules in case of emergency. The extra out-of-pocket costs you might have faced for receiving non-network care is often waived in emergency circumstances. Be aware, however, that once you’re discharged from the emergency room any additional care you may receive from the same non-network health care providers – even if it’s related to what you were seen for in the ER – may not be covered. Ask your insurer or licensed agent about how your plan works in emergency situations.

Pay attention to provider networks when shopping for coverage

Anytime you’re shopping for a new health insurance plan, make sure you pay special attention to the provider networks offered to you. Will you have access to doctors and hospitals nearby? How far are you willing to drive to see a network medical provider? If you have a favorite doctor that you want to keep visiting – and many of us do – then you’ll also want to check his or her network status when considering any new health insurance plan. Articles like this can only provide general information, so be sure to familiarize yourself with the benefit details of any plan you are considering to decide if it suits your individual needs. 

How to see if your doctor is in network before choosing a coverage plan

Besides searching through insurance membership materials or visiting the website to research there – the fastest way to discover if your provider network covers your regular healthcare services is to call the customer service phone number and ask them to look up the data in their system. Before calling, prepare a list of all the current professionals and institutions – a doctor, hospital, special clinic, psychologist, physical therapist, convenient neighborhood pharmacy, etc. that you wish to continue utilizing. Have your provider ID numbers and plan information available so the representative can look up your specific plan and verify the in-network providers. 

If when switching plans it becomes clear that your doctor is not included in the medical provider network, it may be because the company could not negotiate a deal with that person or that there was no opening for that particular service within the medical provider network.   

eHealth can help you find a plan that gives you access to doctors you prefer

If you want assistance with shopping for health insurance, a licensed health insurance agent can help you find a new plan that meets your needs and budget and gives you access to the doctors you want to see. Whether you’re shopping for individual and family health insurance or small business health insurance, eHealth has great online resources to help you check which plans are accepted by your favorite doctors.