Going out-of-network
Most health plans negotiate rates with providers in their network. But if you use an out-of-network doctor or hospital, the fees can vary significantly. You could be responsible for a sizable chunk of the bill or, if you're with an HMO, perhaps the entire bill. So make sure you really need to go out of your network, and if you do, first do some research and then some negotiating.
Decide if you need to go out of your network
That can make sense if you're seriously ill and need a hard-to-find specialist. But talk with your insurer first to make sure you really don't have access to a qualified provider or in-network hospital.
Get information about costs
Ask the out-of-network provider how much he or she will charge for the procedure. Or use www.healthcarebluebook.com, a free resource that provides information on health-care costs, to get an estimate.
Also find out how much of the cost you'll have to cover if you go out of your network. You might have to pay a higher deductible as well as a higher percentage of the cost, or co-insurance. You can get estimated out-of-network rates in your area and the amount typically covered by health insurance plans by using the Consumer Cost Lookup tool from FAIR Heath, a nonprofit organization that keeps a database of provider charges for health-care procedures and services. Then ask your insurer how much it will cover. Insurance generally won't pay for any portion beyond what the company considers "usual and customary." So make sure you know how much that is.
Negotiate
Ask your out-of-network provider to accept your insurance company's payment for services as payment in full. If that doesn't work, make sure the charges compare reasonably to the out-of-network rate from FAIR Health. If they don't, and you don't have a medically urgent need, consider shopping around. You might even be able to receive full in-network coverage if the procedure is medically necessary and your network doesn't have a specialist who can adequately treat you. Ask your doctor to help you make the case to your insurer.
Beware of going out-of-network unintentionally
Your doctor might unwittingly refer you to an out-of-network doctor, or the hospital you end up in might use providers, such as anesthesiologists or radiologists, who don't participate in your plan. To avoid those surprises, always ask if the provider or hospital you're being referred to is included in your network. And before scheduling a procedure, ask your coordinating physician to find specialists in your plan.
If you find that you unknowingly used an out-of-network provider, you can still negotiate. Dispute any charges you think your insurance company should cover, and don't pay until you have exhausted all your options. Let your doctor or hospital billing department know that you'd like to work toward a resolution, and offer to pay the in-network rate or a higher amount that you can still afford.
