Navigating Insurance Coverage

In and Out-of-Network Benefits

In-Network and Out-of-Network

Everyone uses different criteria to select a new doctor. But, is the insurance company’s network part of your list? You may wonder, “How does it impact me and why should I even care?” Paying attention to whether or not your healthcare providers are in your insurance company’s network is a good idea and an excellent way to save, or at the very least avoid paying more than what’s necessary. While in-network and out-of-network terminology sounds confusing, this guide will help you to understand the impact of your insurance company’s network.

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What is a Network?

Your insurer has identified a group of providers who are “in-network” and has contracted with these providers on your behalf to get services at “discounted” rates. The primary advantage of using an in-network provider is that you receive this negotiated or discounted rate for their services, and your insurance generally picks up a larger portion of the bill than with an out-of-network provider.

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Understanding How In-Network vs. Out-of-Network May Affect Your Pocketbook

An example: A visit to an in-network physician may charge $100 for an office visit. Your insurance company has contracted with them to discount this visit to $60. If your insurance company covers 80% of the cost, the patient responsibility would be $12. Compare with an out-of-network physician that also charges $100 for the visit. Without the negotiated rate from your insurance company, your cost will remain $100. For out-of-network providers and care, your insurance may only cover 50%, making your patient responsibility $50.

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I Went to an In-Network Provider. Why Weren’t All of my Services Covered?

Remember, just because a provider is in-network, it does NOT mean all the healthcare services and treatments you receive will be covered. Using an in-network provider simply means that when you receive services from the provider, your insurance will get you the negotiated rate for the services. They will then provide you with the coverage outlined in your policy. Insurance plans can be confusing, so make sure to check your insurance policy.

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Issue 1: Are They In or Are They Out? How Do I Find Out Who’s In-Network?

Doctors frequently move in- and out-of-network. The day the network book is printed or the website is updated, it’s out of date. Doctors have been added. Doctors have failed to renew their contract or opted out of a network. Basically, the information is out of date, and until you check with the provider, you really don’t know. Check with your provider when you schedule a visit or before you receive services (when you check in for the appointment). They will need to know your insurance, possibly your group number as well as your “network.” All of this information should be on your insurance card.

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Issue 2: The Out-of-Network Service Provided through an In-Network Provider

It’s possible to go to an in-network provider and receive services from a provider who is out of-network. A common example might be that you go to a physician for a checkup and have lab work done. The lab company may be out-of network.

Another fairly common example is that the hospital where a surgery is performed may be in-network but the anesthesiologist is out-of-network. Awareness that this could happen is the first step to prevention. When you are verifying an appointment of this nature, be sure to ask network questions. If you specifically asked and were not told ahead of time that you were receiving services from an out-of-network provider, the out-of-network provider may be more likely to provide in-network pricing. Contact your insurance company and make them aware of the situation and enlist their help in sorting out what an in-network price should have been. They will have leverage with the providers that you may not.

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Issue 3: I Want to Use an Out-of-Network Provider

As we’ve discussed, going to an out-of-network provider tends to be more expensive, but it happens. Sometimes you can’t help being out-of network if you’re out of town or your current insurance plan has a limited network. Be up front with the provider. Tell them you know they are out-of-network and that you would like to receive the in-network negotiated rate if possible. Get that from them in advance and in writing to save yourself countless hours of headache and expense later. Also, be aware that your payments may not be applied to your deductible. Once you’ve met your deductible, out-of-network expenses may be your responsibility to pay either in full or a substantially larger portion. It’s a good idea to check with your insurance carrier to make sure you understand your plans specifics. Being aware of the potential exposure and knowing the appropriate questions to ask will help you to navigate the system.

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How to Handle a Denied Medical Claim

Explanations of benefits (EOBs) from the insurance company are complicated and difficult to understand. It’s no wonder they are frequently tossed aside – unopened. However, that EOB is critically important! It explains how much of the claim your insurance company covered and paid to the provider, or it may reveal that your claim was denied. A denied medical claim is anything but welcomed, and often arrives without warning. This occurs when your insurance company does not approve payment for treatment or other medical services. A denied medical claim can happen for a number of different reasons, even sometimes legitimately. Here are some examples: you have hit your maximum lifetime benefit, you have received a non-covered service or experimental treatment, the provider coded the services incorrectly, you might have a pre-existing condition that is still not covered. The list goes on. That’s why it is important to open and read your EOB. Once you start opening your EOBs, knowing how to handle a denied claim and the insurance company’s reason for denial, makes the process of appealing the claim a little bit easier and somewhat less stressful.

Preventative Measures

Understand Your Insurance Policy and Benefits

Knowing what your plan will and will not cover, prior to a procedure or doctor’s appointment, allows you to make more informed decisions about your healthcare. Depending on your carrier and benefit plan, this information will be outlined on the insurance company’s web site or is available from your HR department.

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Know When You Need to Obtain Pre-Authorization

It is your responsibility to know when you need to obtain pre-authorization for a procedure or doctors’ appointment, and to make sure you and/or your provider receives approval. You can also find this information in the benefit plan documentation or by calling the insurance company’s customer service.

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How Do You Know if a Claim is Denied?

You already paid your co-payment and saw the doctor. It’s over and done, right? Well not exactly. No one particularly enjoys sorting through the paperwork after a doctor’s visit or surgery, but the EOB, sent by your insurance company, is one of the only ways to determine what the insurance paid to the provider and how much you may still owe. It will also disclose if your claim has been denied! How do you know? For starters, the insurance company payment will show $0. This may or may not be a denial depending on your insurance policy, but this $0 payment should be followed by a “Reason Code(s),” which will provide an explanation for the lack of payment. If you’re lucky the insurance company will send you a letter confirming the denied medical claim and detailing their reason(s) for denial.

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How to Appeal a Denied Claim?

If all or part of your claim is denied and you have reason to believe it should be covered, follow these steps:

Step 1:

Collect and organize all information pertaining to the denied claim. Make sure you have the original bill (containing the date(s) of service and the Providers’ name), your EOB and your insurance card before placing a call. If the insurance company sent you a letter, have that available as well. Most importantly, review a copy of your insurance policy and know what part of the policy leads you to believe this claim should not have been denied.

Step 2:

Call the number provided on the letter from your insurance company, or if you did not receive a letter, the customer service number. There is a possibility the claim was denied because of missing information. Once the missing information is provided, the claim will be re-processed, and you’re done. If this is not the cause, ask the representative for suggestions or guidelines for appealing a denial. If you would like an appeal form, ask them to send one via the mail or email. Make sure you have the address for the appropriate department to return the completed appeal documents. Always keep a record of the date, time and the name of the customer service representative you talked with, along with a brief summary of the discussion. Keep this with copies of any documents you send to the insurance company.

Step 3:

In appealing the denied claim, you should have the opportunity to review the information the insurance company used to make their decision. If necessary, get your doctor involved. Their office has staff that can help explain, and even send a letter explaining why the procedure/care was needed, or “medically necessary.”

Step 4:

Remember each insurance company has its own appeal process and time constraint, or deadline, for appeals (typically 90-120 days from the date of service). Before submitting your information, make sure you have completed and include all required paperwork per your specific insurance company’s website or customer service representative. Once all documents are complete, make a copy of everything for your reference.

Step 5:

If your insurance company denies the claim again, in most cases, you can contact them to request an external appeal, which will be conducted by a medical professional not associated with the insurance company.

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NOTE: Remember to stay calm as you're talking on the phone with an insurance representative. A written appeal that is clear and factual carries more impact than a lengthy emotional telephone call