NETWORK – Is my provider “in-network” with my insurance plan?
NETWORK – Is my provider “in-network” with my insurance plan?
If you already have certain medical providers you prefer and want to make sure you’ll still have access to those providers, you’ll want to sign up for a plan that is accepted as an in-network insurance by your provider. If you stay in their provider network, the benefits on your plan will actually apply to your visits and you’ll receive a much lower rate than you would if you went out-of-network.
Because a person may see multiple providers and every provider has their own list of accepted insurances, you may run into a problem finding a single plan that is accepted by all of your preferred providers. Or, once you find that plan, you realize it is just way too expensive and cannot afford to sign up, so it is effectively inaccessible. In this situation, you’re going to need to make some type of compromise. You should start by assessing the true cost of the care you expect to receive and focusing on your largest possible expenses first.
No matter where the line of “affordability” lies, it is obvious that a PCP visit is at least “more affordable” than an emergency room visit. If you had to pay for one of those yourself, you’d much rather it be the $100 PCP visit rather than the $5,000 ER visit. While you can still manage to incur some pretty significant medical costs with frequent primary care offices and specialists, the out-of-pocket expenses will never be on the same level as a single visit to the hospital. Because primary care visits at Family Care average around $100 per visit if they are not covered, you’d have to have non-covered primary care visits twice a week for an entire year to match the cost of a single accident that landed you in the hospital.
With most health expenses, the bills escalate quickly due to a few common types of services:
- Hospital Visits. Just one night in the hospital could cost more than $10,000 if you don’t have insurance, so these visits create the majority of medical debt.
- Surgeries. A single surgery can sometimes cost more than $5,000 and often requires several costly follow up visits to make sure you are recovering well.
- Tiered Medications. For drugs that have very specific indications or are considered upper-tier level medications, out-of-pocket costs can be up to $1,000 per month.
Because we are dealing with a situation where the insurance company is putting the obligation to pay the claim on the patient, this is basically an extension of our previous discussion on covered services, in general. Being “out-of-network” is one of the most commonly used reasons for an insurer to deny coverage for a particular service, so your plan’s network really has a big influence on your expected out-of-pocket expenses for a certain service. For example, the price of the same EKG at an out-of-network cardiologist could be 500% more expensive than if it were performed by an in-network cardiologist. That is actually kind of crazy when you think about it, but that is for another article.
There are a few different ways to find out which providers are in your network.
- Call your insurance company. There is always a customer service number you can call to speak with a representative from your insurance. Ask them to send you a list of the providers in your area that accept your insurance. Usually, they will either read you a list over the phone, email you PDF file, or direct you to the content on their website.
- Visit your insurer’s website. Most insurance plans have a “Provider Finder” tool somewhere on their website. Make sure you select the proper choices from all of the possible search filters to ensure that the list actually applies to your plan.
- Call the provider. Each provider will know which plans they accept, so you could ask them as a starting point. Make sure know the name of the company (eg. BCBS, Cigna) and the name of the specific plan (eg. Blue Advantage, Choice Plus), as both of those are required to verify your coverage. Even if the provider says they accept your plan, you may want to double check with the insurer, anyway, as they will be the ones to ultimately process your claim and make that decision.
In order to maximize the amount of coverage you receive from your plan, you should try to stay “in-network” for as many services as possible. Plan to be “in-network” for the big expenses first, because that will make the most difference in your yearly out-of-pocket spending. There are many plans that actually offer pretty good out-of-network benefits, but they will still always be at least some margin less than your in-network benefits.
It’s good to know that a healthy individual can lead to fewer insurance costs for medical services. I need to get a health care plan since it’s my first time being off of my parent’s plan and I can’t decide which one to get. I’ll be sure to keep researching and find different benefits that fit my lifestyle and what I want.
I like how you mentioned that cost, coverage, and network are all things you need to consider when choosing a healthcare plan. My brother is thinking of looking for a medicare plan provider because he’s considering getting medical insurance in case of an accident that would injure him at work or if he gets sick. I think it’s a good idea for my brother to consider all of his options when choosing a reputable healthcare plan that would provide the coverage he needs for his medical needs.
These are all great points to consider when it comes to health insurance. Not all plans are the same, after all, so unless you’re working directly with your employer, it’s important to shop around.