Doing your best to obtain medical care from in-network health care providers is important if you are worried about high medical costs. Here are the steps for how in-network coverage is provided during a medical visit.
Provider: The patient receives treatment. The doctor then sends the bill to the insurance company (the address on back of the patient’s health plan ID card).
Network: Appropriate discount for using an in-network provider is applied.
Bill: The bill for services is presented to the insurance company. Payment responsibilities are calculated and divided between the patient and the insurance company.
Insurance Company Payment / Explanation of Benefits: Insurance pays for its portion of the bill from the provider. A summary of charges and insurance payments is sent to the patient via the insurance company.
Patient: Patient pays doctor’s office for copayments, deductibles and/or co-insurance that he or she is responsible for.
Going to an in-network provider is almost always less expensive and easier, but your choices will be more limited. The payment for covered services is sent directly to the network provider, which results in less work for you.
If you decide to go out of network voluntarily, there are several resources that can help you make the best financial decisions, such as www.fairhealthconsumer.org/. This nonprofit is dedicated to helping consumers receive and estimate health care cost information.
If possible, do your research on local providers that are covered by your insurance before any care is needed.
Calling the physician directly and double-checking with your insurance company is the best way to ensure that the provider is in-network. If you are receiving surgery, make sure to ask if the service is completely in-network. Often times, things such as anesthesia are not covered even though the primary physician is in-network.
Staying in network not only means less money out of your pocket—it’s easier!