In-Network vs. Out-of-Network

In-Network vs. Out-of-Network

Hey everyone, Kelcey here again! Back with my next blog regarding basic insurance information that may be helpful to know! Today, I wanted to discuss the difference between an In-Network Provider and an Out-of-Network Provider and how it affects you as the member. Additionally, I will touching on recent change of Measure 17, which removed restrictions of insurance companies on the providers.

** Please Note: I am not an insurance expert. All terms and actions are explained to the best of my abilities and in accordance to Excel Chiropractic’s policies and procedures (aka: very by the book, we love to follow the rules here!)

***Also Note: These are basic terms and explanations. I will explain what occurs with the MOST COMMON insurance plans. There are outliers that exist to throw everyone for a loop. Ultimately, there is no guarantee of benefits and they will be full determined when the claim is processed (aka: we will abide to the benefits presented to us when we receive the claim back from the insurance company. This means your benefits may be different from what we were originally told.)

·         In-Network Provider: Refers to providers or health care facilities that have negotiated a contract with an insurance company.

o    These providers have submitted an application into the insurance company to become a part of the network.

o   Once accepted into the network, the provider agrees to accept your plan’s contracted rate as payment in full for services

o   That contracted rate includes both your insurer’s share of the cost, and your share. Your share may be in the form of a co-payment, deductible, or co-insurance.  

§  Insured individuals pay less when using an in-network provider because those networks provide services at lower cost to the insurance companies with which they have contracts.

·         Out-out-Network Provider: Providers who have not agreed to any set rate with your insurer, and may charge more.

o   Your plan may require higher co-pays, deductibles and co-insurance for out-of-network care than for in-network providers.

o   Your plan may not cover out-of-network care at all, leaving you responsible for the bill in full.

·         Measure 17: A measure passed in 2014 that requires all health insurers to include all willing and qualified health care providers on their provider lists

o   There is an important key phrase to remember here: The provider must be willing to be a part of that network. This means that the provider must submit an application, go through the insurer’s credentialing process, and agree to the contracted rates before they can be considered an in-network provider. If they chose not to do this, they will remain out-of-network, even if you chose to see them.

§  An insurance company cannot be forced to include a provider who has not gone through their credentialing process.

§  Additionally, there may be certain conditions that the provider does not meet, and thus cannot be a part of that network.

·         For example: Some Blue Cross and Blue Shield of MN plans only include providers in the state of Minnesota.

The easiest way to find out if your chosen provider is considered in-network with your insurance company is to call the Member Services phone number which is located on the back of your insurance card. Give the representative the doctor’s name and practicing location and they should be able to tell you whether or not he or she is in-network.

Also, it never hurts to ask the provider directly if he or she would be willing to join your health insurance network. They may have their reasons for staying out of that particular network or they may not even know that they’re weren’t in-network to begin with! 

If you have and questions or concerns regarding these terms or any insurance information, please do not hesitate to give me call. I will do the best I can to help!