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What is “Out-Of-Network” (and how can you avoid it)?

Out-of-network: Three little words, a big impact.

It’s happened to one in five people in the US: you receive medical care and a few weeks later, a piece of mail arrives, telling you that the doctor, specialist, or the service provider you saw was “out-of-network.” Maybe you’re not quite sure what that means. And you’re even less sure how it happened, or if it’s actually correct. But what you DO realize from the paperwork? There could be a hefty bill on the way.

Don’t panic. We’ve got your back.

Naviguard was created to help patients deal with out-of-network medical bills and to provide guidance on how to avoid them in the future. Our insurance specialists and expert negotiators have decades of health care experience and work on behalf of patients to reduce out-of-network bills. It’s our primary focus.

For patients in a participating plan administered by UnitedHealthcare, there is no additional cost for the member to use Naviguard’s bill negotiation services. Ask your employer or call UnitedHealthcare Member Services to find out if your health plan includes Naviguard.

In this article, we’ll focus on exactly what “out-of-network” means, how it happens, and what to do if you get an out-of-network bill.

Out-of-Network: what it means

Insurance companies contract with certain providers and facilities to secure a network discount for the services they provide. Those providers are considered “In Network.” Out-of-network means that no contract exists between the provider and insurance company. As a result, if you see an out-of-network provider, then you could be held responsible for the full amount of the bill. In many cases, out-of-network providers charge prices significantly higher than market rates.

 

How out-of-network medical bills happen (and how to avoid them).

Under the No Surprises Act (NSA), providers of certain types of services are prohibited from billing you directly for certain surprise medical bills, beginning on the date when your health plan starts or renews in 2022. But this protection only applies to certain services, like emergency services (excluding ground ambulances) or when an out-of-network provider is involved in your care at an in-network facility. Which means, there are still ways to wind up with bills for out-of-network charges. And you may be responsible for them.

Knowing how these bills happen gives you power to prevent them.

1. No prior agreement with provider

Outside of the surprise bills covered by the NSA, you may face out-of-network bills that are not covered or that exceed the allowed amount under your health plan. This can happen if you see a provider that hasn’t agreed to a negotiated fee with your insurance provider. This means those providers may charge you the difference between the full price they ask for your treatment and the amount allowed and covered under your health plan, leaving the burden of payment up to you.  

  • Prevent it: Understand your health plan thoroughly—from who’s in the provider network, to your family deductibles, to your co-pays and co-insurance. If you choose to see a provider that’s not in your network, get an estimate of the costs in writing ahead of time. If your health plan includes some out-of-network benefits, understand those ahead of time so you’re better prepared for the bill.  

   

2. Referral from your in-network doctor

When your provider suggests you see a specialist or have a procedure, you may assume—incorrectly—that it’s all covered. Outside facilities, lab work, pathology, and some specialty providers, like radiologists and anesthesiologists, assistant surgeons, etc. may be out of network.  

  • Prevent it: Verify every provider, and every procedure with your insurance plan administrator ahead of time. If a service or specialist is not in network, ask your primary doctor for in-network options. If there aren’t good in-network options, get an upfront estimate for out-of-network costs.  

  

3. Ambulance costs

While the new No Surprises Act prohibits providers from billing patients for certain types of services, including emergency care (and air ambulances), you may still be billed by out-of-network providers for the ground ambulance ride to a hospital, and for the difference between the total bill and the amount allowed and paid by your health plan. 

  • Can you prevent it? Not always. But it’s helpful to know ahead of time, and seek the use of an ambulance only when it’s really necessary.  

 

 4. Waivers may work against you

An out-of-network provider may ask you to sign a form that waives some of your No Surprises Act protections. This is referred to as the notice and consent process. Be sure to read any agreement you are asked to sign, especially if it includes cost estimates—and ask questions about what you’ll have to pay beyond what insurance covers.  

Remember: Occasionally, claims are incorrect. They may be able to be reprocessed at your in-network benefit level.

There are a lot of moving parts in health insurance billing, from what the provider submits to your insurance to the Explanation of Benefits you receive—which means there’s always the possibility of errors. Even if the math looks correct, claims can be mistakenly processed as out-of-network for a number of reasons:

  • A referral from your doctor for another provider/specialist/service was missing at the time your claim was processed.
  • An ancillary out-of-network provider, such as an anesthesiologist, submitted their claim before the in-network facility did.
  • An emergency situation was processed as a non-emergency.

 

If you think the out-of-network claim is wrong or your plan benefits were applied incorrectly, contact your insurance plan administrator right away. Or, if you think you’re missing a referral, give your provider a call. Responding quickly can help keep incorrect bills from filling your mailbox.

 

Use our expertise. We’re here for you.

At Naviguard.com, you’ll find a variety of resources, including helpful tips on avoiding, understanding, dealing with and negotiating out-of-network bills.

Naviguard members (those whose employer-sponsored health plans include our services) can use our full suite of resources and services, which will lead you step-by-step through an out-of-network billing claim and help prepare you to negotiate with out-of-network providers. If you’re a member with a qualifying out-of-network claim we may be able to pair you with a dedicated Patient Advisor, who will personally guide you through the entire process, and depending on the claim, even negotiate with providers on your behalf. We’re here to help however we can.