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The Top Out-of-Network Risks

When it comes to your out-of-network health care, or services administered by a provider who is not contracted with your insurance company, the more you know, the better. Easier said than done, right? Well, that’s exactly why we’re here. We help people navigate the confusing world of out-of-network health care so they can make smart decisions about their care and steer clear of bigger-than-budgeted bills.

More than half of Americans have received an unexpected out-of-network bill.1 What’s the secret to NOT getting one? Get ahead of them. In other words, know when you’re most at risk of going out-of-network so you can prevent it from happening the first place.

But before we get into the specifics of it all, let’s start with the basics.

First things first: What does “out-of-network” care mean?

“Out-of-network” means there is no contracted, negotiated rate between the health care provider and your health plan. The provider can and may bill the patient the difference between their charged amount and the out-of-network allowed amount. So you might be on the hook for the balance (which is why these are sometime called “balance bills”).

How to know what’s considered “out-of-network” for you?

Every health care plan is different. Get familiar with yours to know what you’re responsible for paying and to plan for potential bills. Before any visit, surgery or procedure, log into your account to check your plan details, then use an online provider search tool to see if your doctor is in your network. You can also call the number on the back of your insurance card to find an in-network provider. Trust us, taking the time to understand your plan now is worth it.

OK, now let’s dive into the details.

What causes out-of-network medical bills?

Usually out-of-network bills happen when your doctor involves additional providers or specialists, often through referrals. You likely don’t schedule appointments directly with them but they’re important for treatment and diagnosing, like radiologists and lab techs. These providers may operate separately from your main provider, which means they could be out-of-network for your health plan.

Under the No Surprises Act (NSA), providers of certain types of services are prohibited from balance billing for certain surprise medical bills, beginning on the date when your health plan starts or renews in 2022. But this protection only applies to specific services, like emergency services or when an out-of-network provider is involved in your care at an in-network facility. Ground ambulances are not covered by the NSA protections and may still seek to balance bill you. Which means there are still many ways to wind up with expensive bills for out-of-network charges that you’re responsible for.

The good news: Many out-of-network costs CAN be avoided!

It just takes a little bit of effort up front to possibly save a lot of money down the line.
Here’s what you should do to outsmart out-of-network costs: Before any medical visit or procedure, ask your physician what providers and services will be involved. Then, check to see if they’re on the list below.

The Most Common Out-of-Network Care Situations

Getting Referred to a Specialist
When you’re referred or scheduled for a procedure outside of your primary care facility or provider.

Managing Pain (Injections)
Any procedure that requires local or general anesthesiology, or being “put under,” means an anesthesiologist is needed to administer it.

Leaving a Sample
When you leave a sample (like blood or urine) it is sent to a laboratory for expert analysis.

Getting Scanned
MRIs, X-Rays and CT scans are all examples where a radiologist is needed to review the scan.

Having Something Removed
A biopsy involving organs, tissue, bodily fluid or cells will require a pathologist for analysis.

Someone is Helping with the Procedure
For more complicated procedures, doctors and surgeons often bring in a Physician Assistant or Surgical Assistant.

Ground Ambulances
In an emergency, there’s not enough time to ensure the available ambulance provider is in-network.

If none of these scenarios apply to you – good, you shouldn’t be at risk for an out-of-network bill. However, you should always check your plan and ask at every step of the way to be sure.

On the other hand…

If the service you’re getting IS on the list:
Stay calm, you don’t need to worry just yet. If any of the services on the list are happening at an in-network facility, the risk of balance billing is very low. You can try a few things to get in-network care or minimize costs:

  1. Call your provider and see if there’s an in-network option they can schedule.
  2. Call the hospital or surgery center to see if they have any in-network providers that have privileges to perform care at that facility.
  3. Ask if you can get an upfront estimate for their services.

And remember, Naviguard is here!

Our purpose is to help members in Naviguard participating plans deal with unexpected out-of-network bills—and we have a proven track record of success. We review your bill to help ensure you’ve actually been billed correctly and we negotiate with providers on your behalf for a lower billed amount when appropriate.

Our services are currently available at no additional cost to UnitedHealthcare members in Naviguard participating employer benefits package plans. If you’re not a Naviguard member, our resources can help you avoid costly, preventable medical bills and help you understand every detail of your medical bills. Plus, Naviguard can help you get organized, gather the necessary paperwork and build your case for negotiation and resolution. To learn more about the services we offer, talk to your employer or visit our About page.

P.S. Finding in-network care is easy with the UnitedHealthcare Provider Search tool.