In- vs Out-of-Network Providers

Looking for ways to save on health care costs? Stick with the network.

Using the network will save you money

A network is a group of health care providers, including doctors, specialists, dentists, hospitals, labs and other facilities. These health care providers have agreed to provide medical services to health insurance members—you and your covered dependents—at discounted costs. When you join a health plan, you become a member of the club (so to speak). You get access to the same services you would receive from any other provider, but as a member of the network using a provider in the network, you pay less.

The amount you pay, also known as the contract rate, is lower than what the doctor or facility would charge if you were not a member of the network. All you pay when you visit a network provider is your copay, coinsurance or deductible, depending on the service you receive. You get the care you need at a discounted cost, while visiting providers you know and trust.

Using out-of-network providers

There may be times when you decide to visit a provider that is not in the network. You will pay more for care because out-of-network providers have not contracted with our insurance company; therefore, they will charge higher fees. The fees may be reimbursed at a lower rate, and you could be responsible for paying charges above what your health plan considers “reasonable” for similar services in your area.

There are also more steps to take when using an out-of-network provider. You may have to get a referral from a network doctor in order for your care to be covered at all. You may also have to pay the full cost of the visit, and then file your own claim forms to be reimbursed for a portion of what you spent.

Your action plan: don’t get surprised by the bill

There are times when going outside your network for care may be unavoidable—like getting sick or injured on vacation. But going outside the network for planned care, especially for something major like a surgery, can be quite costly. To avoid higher out-of-network fees, ask the provider’s staff how much he or she will charge for your visit. Or, call around to different providers in your area so you can choose a provider with more reasonable rates.

Remember, you are your own best advocate. No matter what kind of care you are seeking, speak up and ask questions up front to get the best care and avoid being surprised when you get the bill.

Did You Know?

Finding an in-network provider is really easy! Talk with your HR department or contact your Diversified Team at 262.439.4800 for a list of providers in your area.


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