In-Network vs Out-of-Network

If you’ve ever wondered why some doctors, dentists, or hospitals take your insurance while others don’t, it’s because some healthcare providers are “in-network” while others are “out-of-network.” Look at your insurance card; it will have information about your coverage—specifically, which healthcare providers are in-network and which are not. Knowing the difference in care can help you save money, but things aren’t always cut and dry.

What is In-Network?

Insurance companies partner with healthcare providers, entering contractual agreements for negotiated or discounted service rates for members. The various healthcare providers who have accepted contracts with your insurance company are called the network of providers. When you (the member) visit one of them, you receive in-network care.

Why is In-Network Care More Affordable?

Because providers are under contractual agreements with your insurance company, they cannot charge you more than the negotiated rate. As a result, you will pay considerably less when receiving in-network medical care than out-of-network care.

From a technical perspective, when you visit an in-network provider, your insurance company gets charged the lower negotiated price. You handle a copay or a percentage of the cost. These out-of-pocket costs usually apply to your health plan’s deductible and out-of-pocket maximum.

What is Out-Of-Network Care?

Out-of-network providers are those healthcare providers that are not partnered with your insurance company and thus fall outside your health plan’s network. Since out-of-network providers are not in a contract with your health insurance plan, they can charge whatever rates they want. This typically means you will pay more or the full price for their services.

Perhaps the most common example is if you or a family member have a rare illness or genetic disorder that requires unique skills or a specific procedure. However, before looking outside your network for a specialized provider, speak with .your in-network primary care provider first to see if they can help you find an in-network option. 

Another common reason people choose out-of-network care is during a medical emergency. 

Also, people traveling in need of medical care may choose the most convenient option over searching for in-network care. Similarly, those in rural or remote areas may have limited options for in-network providers, underscoring the advantage of telehealth. 

Additionally, if you have an established relationship with a healthcare provider, like a family doctor or physician, you may decide to continue seeing them despite potentially paying more because they are out-of-network.

Additional Conditions When Using Out-of-Network Care

Before signing up for a health insurance plan, see if your current providers (doctors, physical therapists, mental health care professionals, etc.) and healthcare facilities (hospitals, pharmacies, urgent care clinics, etc.) are within the plan’s network.

If one of your preferred providers is not within a health plan’s network, see if the plan offers out-of-network benefits.

Some plans may offer out-of-network benefits, which still costs more than in-network.

Recall the situation where someone has to go out-of-network because they or a family member has a rare disease or condition. In such scenarios, you can appeal to your insurance company by explaining your situation to your primary care provider or an in-network specialist. They may work with you to get approval from your insurance company so that you can receive out-of-network care.

Learn more about Antidote Health’s Provider Network

Antidote Health has an extensive network of quality providers, covering a range of services from doctors to pharmacies to dentists. If you receive services from an out-of-network provider, they can submit a claim to us, or you can file the claim directly.

Contact Antidote Health today with your questions about our network or out-of-network care.