Lowering the barriers to
well-being
- Out-of-network providers may charge more than in-network providers
- Reduced quality of care and surprise balance bills may occur if care is received from an out-of-network provider or facility
- Out-of-network health care costs don’t have to be a major barrier to well-being
When going out-of-network for health care is necessary or unavoidable
Chances are, you’ve heard this before: Going out-of-network for health care may cost you more (maybe a lot more) than if you stay in-network.
Yes, but there may be times when going out-of-network is necessary and can’t be avoided. Times when it’s the best option for you or someone in your family. Times when you shouldn’t skip getting care because it’s out-of-network.
It's a common understanding that going out-of-network for health care can result in higher costs compared to staying in-network. However, there are situations when going out-of-network is necessary and unavoidable, such as when you have a trusted doctor who understands your health issues but isn't in your network, or when the best specialist for your condition is out-of-network. In emergency situations, receiving unplanned medical care from an out-of-network provider or receiving services from an out-of-network provider at an in-network facility may also be unavoidable.
For example: What if you have a trusted doctor who knows you and understands your health issues but isn’t in your network. Or if the best specialist in your area for treating a particular condition is out-of-network?
There are many reasons people wind up using more costly out-of-network providers. Here are four things to keep in mind that may help preserve your finances and peace of mind.
In-network versus out-of-network health care
When you choose a health care provider that is in-network with your insurance company, they have negotiated discounted rates for their services. This not only helps ensure that you receive quality care, but also decreases the chances of conflicting treatments or unnecessary tests1. On the other hand, if you choose to use an out-of-network provider, it may cost you more and you will be responsible for coordinating your own care. Keep in mind that a primary care provider may coordinate with about 95 physicians.2 While you may not need to coordinate with that many, it can still be challenging to manage your care with multiple providers.
Surprise, surprise
Out-of-network providers may send you a balance bill. (Of course, you may be very surprised by the amount.) But there are three situations in which you may have protection from balance billing.
One situation is if you need emergency care and unknowingly get it from an out-of-network provider or facility. The second is if you go to an in-network facility, but one of the care providers was out-of-network. For example, a surgeon's assistant or an anesthesiologist. The third is if you receive air ambulance services.
In these three situations, balance billing is not allowed when federal law applies the No Surprises Act. If you think you have been balance billed, contact your insurance company and ask them to review your bill before you pay it.
There may not be a maximum to your out-of-pocket costs
Chances are, your health insurance plan has an out-of-pocket limit to protect you from unlimited medical costs. As the term implies, it places a maximum or cap on the total amount you’ll have to pay each year. This total amount includes your deductibles, copays and coinsurance.
Since the out-of-pocket maximum may be the only thing protecting you from financial ruin if you develop a costly health condition, getting out-of-network care may dramatically increase your financial risk.
Naviguard is here to help negotiate out-of-network medical bills
Naviguard® is a UnitedHealthcare service that uses advanced analytics, and effective strategies to review and resolve out-of-network balance medical bills.
Our advisors provide information, guidance and education through the entire bill resolution process. If needed, our expert negotiators directly negotiate with health care providers to resolve any disputes related to balance medical bills.
We have decades of health care experience and use reference-based pricing and provider network knowledge — all to resolve out-of-network balance medical bills. Our goal is simple: to help you avoid paying too much for out-of-network health care.
Naviguard is available, at no added cost, to UnitedHealthcare members whose plan includes our services. Think you may benefit from Naviguard? Learn how to get started.
RESOURCES
- Learn about services with high risk for balance billing
- Learn more about the services Naviguard offers members
- Learn how Naviguard has helped others reduce balance medical bills
REFERENCES
- "Care Coordination" Centers for Medicare & Medicaid Services, March 12, 2024
- "Pathways for Specialty Care Coordination and Integration in Population-based Models" Centers for Medicare & Medicaid Services, March 12, 2024