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"In Network" vs "Out of Network": essential facts to know

Updated: Sep 15, 2023

By Martine G. Brousse

"The Medical Bill Whisperer... and insurance stuff too"

Patient Advocate, Certified Mediator


Watch the YouTube video:

July 6, 2023

You’ve seen the terms when scrolling through the list of claims on your online insurance portal. They may have appeared on medical bills.

For sure, they show up on your EOBS (“Explanations of Benefits”) – more on these below - but what do they mean? What’s the difference? Why should you care? And can you do anything about it?

First a disclaimer: this info only applies to “commercial plans”, meaning a non-government policy, provided by your work or that you bought yourself (UHC, Aetna, BCBS, HealthNet, etc) Medicare, Medicaid and Tricare policies have different requirements.

For Commercial plans – that you bought on the open market or get through your employer – In Network and Out of Network hold immense significance over how claims from medical providers are processed, and what your ultimate cost will be.

1. It starts with the “EOB”

The Explanation Of Benefits (EOB) is the form issued by your insurance which details:

· who billed how much for which services

· how the charges were processed, at “what rate”

· how much may have been paid – or rejected – and

· how much your cost was calculated to be.

Whether processed as “In Network” or “Out of Network” will be reflected either next to the name of the medical provider, or in the note section.

If you see “In Network”, you should be good. If “not in network” or “out of network”, it is a red flag you absolutely must investigate.

2. But what is a “network”??

Think of it as a list of names: persons or places rendering medical services. The list, which can be fluid, is always available through your online account, or by calling an insurance representative.

Your insurance uses that list to calculate their and your financial responsibility

If the Dr or place you get service from is on it, it’s to your financial best advantage. “In” is good, “out” means ouch.

The list has 2 components: “professional” and “facility”.

· Professional means people such as Drs or specialists (your Primary Care Physician, internist, surgeon, the radiologist who read your scan, the ER Dr, your psychiatrist). All types of clinicians and therapists are included.

· Facility means places. Could be inpatient (hospital or mental health residential) or outpatient (ER, infusion center, lab, imaging center, Urgent Care).

3. In vs Out: Specific Differences

Using an In Network provider has advantages:

· The provider is on the special list through a contract or financial agreement

· Your insurance has negotiated prompt, pre-determined and higher payments with the provider in exchange for a discount

· The provider gets preferential treatment when dealing with your insurance – less hassle

· Your yearly deductible and share of cost is lower for In Network claims. You meet it faster, so your insurance pays 100% of your claims sooner.

· Your insurance will grant their OK for services more easily, without appeals and delays.

· The In Network provider must handle administrative tasks directly with your insurance.

Using an Out of Network provider means more disadvantages:

· Your insurance will pay much less, if anything at all

. The Out of network liability is separate and much higher to meet

· You get no discount

· The Out of Network provider can demand payment up front, in full, before you get the service. It can be a “pay it or leave it” situation.

· What or if you get reimbursed for anything becomes your battle

· The Out of Network office will likely hand you an invoice and tell you to handle administrative tasks (appeals, authorizations) yourself.

4. Why should you care?

Do you care about your $?

If you have the choice between option A (affordable with a little advance work) and B (astronomical but I don’t care) what will you choose?

Do you enjoy peace of mind or prefer surprises down the line, however bad they may be?

Do you trust your insurance has your best interest at heart?

Do you enjoy hours on the phone, and getting nowhere?

Or maybe hiring me to clear it all up is your game plan (nothing wrong with that!)

5. So what solution do I have for you?

Before the facts

· Go online, and confirm the Dr/hospital is on the list. Print that page.

· Or call the insurance, and ask them to email you that page.

· Confirm with the office/billing person that they are In Network

· Best is to get a cost estimate in writing

· Why in writing? Cover yourself.

· If you are having a surgery, long term or special treatment, ask about an authorization. The office should get it if needed.

· You may not have the choice of the anesthesiologist or radiologist, or anyone if under emergency circumstances, but for those you can pick: do your due diligence, and check their status ahead of time.

If you end up with Of Network EOBs after the facts, you may be protected by Federal Law (the No Surprise Act), a State law (AB72 in CA), or the terms of your policy. These laws or special circumstances, emergency for example, could force your insurance to pay the highest rate to an Out of Network provider. That provider would also be forced to accept whatever payment your insurance issues.

In this case, filing an appeal to get the claim reviewed and reprocessed is in order.

Asking the provider to get a retro-authorization might be an option.

At last resort, report a provider who willfully violates State or federal laws.

In Conclusion:

· Patients have rights, your insurance has a fiducial duty to you, as do medical providers especially when In Network

· The Federal No Balance Bill act has cut down on the number of bad surprises, as do some States. Don't let the insurance or providers ignore them!

· Always question, do your due diligence, prepare whenever possible or consult a patient advocate like myself to use this hell-thcare system to your best advantage.

what does In Network vs Out of Network mean
In Network vs Out of Network

Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.

(424) 999 4705 - F (424) 226 1330

@martine brousse 2023

@ the medical bill whisperer 2023

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