In an attempt to keep costs low, insurance companies may develop a specific network of hospitals, doctors, and health care providers that they sign contracts with to treat patients at a negotiated rate. These providers are referred to as in-network providers.

Most health insurance companies require their patients to seek treatment only from in-network providers. In fact, you may not be reimbursed for treatment that you receive from an out-of-network provider unless there are special circumstances involved. For example, you may obtain out of network care for emergencies or treatment that you may not receive anywhere else.

The exceptions that surround out of network coverage are a common reason for conflict between health insurance companies and their patients. Even if the out of network care was necessary due to extenuating circumstances, some health insurance companies may be quick to deny a claim based on these grounds.

As a patient, it’s important to clarify to your health insurance company why out-of-network care was necessary. Filing an appeal for a denied claim may be necessary to ensure that you receive the coverage you deserve.

What is Out of Network Coverage?

Out of network coverage refers to healthcare providers who have not been included in the pre-established network of your insurance company. As previously mentioned, insurance companies tend to negotiate rates with healthcare providers before they can include them in their network. This negotiation typically involves the signing of a contract, where the insurance company receives a lower rate for services offered to patients (while the healthcare provider receives more patients in return).

Insurance companies prefer when patients seek care from in-network providers due to the pre-established relationship and lower rate. It’s easier for an insurer to reimburse an in-network provider for services offered to patients. For out-of-network providers, there is typically no negotiated contract for the delivery of care. This means that your insurer will have to pay a full rate for all services delivered to patients.

It can also be more complicated to process payments for out-of-network providers, resulting in higher administrative costs. Many out-of-network providers are actually in-network providers for other insurance companies. Therefore, their operations may have been optimized to suit a different insurer altogether. By seeking care from an out-of-network provider, the costs will most likely be higher than those of an in-network provider. 

Why a Service May Be Considered Out-of-Network

By definition, an out-of-network provider is one who doesn’t have pre-negotiated rates with your insurance company. You may be wondering why a particular healthcare provider is considered out-of-network. This mostly occurs because the provider couldn’t agree with your health insurance company on rates for treatment. In fact, this lack of agreement is the most common reason why a healthcare provider may be considered out-of-network.

There are other reasons why a provider may be considered out-of-network. Some insurance companies keep a small network of providers so as to have more negotiating power with them. Other insurers also take quality seriously, and they may limit the number of healthcare providers in their network so as to ensure the quality of services.

When you May Need an Out-of-Network Provider 

In-network and out-of-network care is a common cause of conflict between patients and their insurance companies. There are many cases where a patient obtained care from an out-of-network provider (whether knowingly or not) and they’re having trouble being reimbursed for the costs incurred.

The following reasons are acceptable for receiving out-of-network care, and most insurance companies should reimburse you for the expenses incurred.

  1. Care received during an emergency

A common reason why patients seek out-of-network care is because of an emergency. Urgent care needed after an accident (or a sudden ailment) may only be available from an out-of-network provider. Most insurers will make an exception for emergency care received from an out of network service. 

  1. When you need specialized care not offered in-network

It’s not uncommon for an insurance company’s network to lack specific types of care that a patient might need. For example, you may require a special type of surgery not offered by any in-network providers. In such a case, you can seek pre-approval for the procedure you need from an out-of-network provider.

Keep in mind that the insurance company has a fiduciary duty to provide you with adequate care options. Some insurers may deny you from receiving the care that you need because you had to go out of their network. Such denials form strong grounds for filing an appeal.

  1. When you have a pre-established relationship with an out-of-network doctor

At the time when you signed up for your health insurance plan, you may have already established a relationship with your current doctor. This doctor may also be the person best suited to meet your healthcare needs, but he/she may be an out-of-network provider.

Most insurance companies are required to approve requests that involve a pre-established relationship with your physician. This approval may only last for a specific time period (6 months to 1 year) as the insurance company works towards finding a suitable replacement for you within its network.

  1. Kidney dialysis services

For patients who require kidney dialysis on a regular basis, obtaining the service from an out-of-network provider may be necessary. For example, if you traveled to an area where the insurance company doesn’t have in-network providers, dialysis from an out-of-network facility may be your only available choice.

Health insurance companies shouldn’t deny you coverage for dialysis services that you urgently need.

How to Obtain Care from an Out-of-Network Provider 

If you have a valid reason for receiving out-of-network care, it’s important to seek pre-approval from your insurance company. Pre-approval ensures that you don’t have any disputes with the insurer regarding payment for services received.

However, it’s not always possible to receive pre-approval for out-of-network care in a timely manner. This is particularly true for emergency services, urgent care, or even specialized medical procedures not offered within your network. In such cases, make sure you keep details of all medical records regarding the procedure.

You should also have the doctor or facility involved prepare a statement that shows evidence of the care you received and why it was necessary. With a valid reason, your insurance company has a fiduciary duty to provide reasonable coverage for your medical treatment.

Further confusion tends to occur when a patient visits an in-network hospital for treatment. While a particular hospital may be considered within the network of your healthcare provider, you may end up receiving care from a specific doctor who is out-of-network.

Indeed, not all doctors working in a hospital may be considered in-network. Some surgeons, radiologists, or physical therapists may offer independent services to patients who visit the hospital. Therefore, you may end up receiving a separate bill for these services.

You can file an appeal for such out-of-network services if your insurer denies the claim. And if the service was part of emergency care (or care for a condition that wouldn’t otherwise be available in-network), you should be able to receive coverage.

Preparing for the Costs for an Out of Network Healthcare Service

If you received out-of-network care and have been sent an invoice for payment, you may be wondering what to do next. Most out-of-network expenses are higher for patients (because you don’t get to enjoy the discounted rates that your insurer may enjoy with in-network providers). For example, an MRI that may cost your insurer $1500 (when received in-network) will cost you as much as $3000 when received out of network.

Non-the-less, out of network care may have been your only available option. For example, you may be pregnant but choose to deliver with your selected obstetrician as a personal preference (and for safety reasons). If your obstetrician is out-of-network, you may end up with a higher medical bill than if the service was rendered in-network.

Another common scenario for obtaining an inflated bill is when your current doctor refers you to an out-of-network specialist. Choosing to follow this referral may result in a higher medical bill on your part. And if you received extra charges for a special service (such as obtaining a private room in a hospital), you may end up being billed separately for that extra service.

For patients who end up with a high bill for an out-of-network service, the following tips are useful options for settling the cost.

  1. File an appeal with your insurance company

The best approach is to explore whether your insurance company can pay for the treatment received. Closely examine your policy statement and look for any loopholes that may justify your out-of-network coverage. If your insurer can cover all or part of the cost, you won’t end up with a hefty medical bill.

Even if the insurer denies your first claim, you should always file an appeal. Consider seeking the help of a lawyer to prepare a strong appeal for your case.

  1. Negotiate for a lower out of pocket rate

Most healthcare providers understand how expensive paying out of pocket can be. If you receive a bill that your insurance company will not cover, you may consider negotiating with the out-of-network provider for a lower rate.

Explain to the provider that you can’t afford the current bill as is, and ask them to reduce it to a more affordable level. Most providers will consider this option as opposed to letting the bill go to collections.

  1. Establish a payment plan to remain in good standing

Another option available is to establish a payment plan for the bill in question. You can split a high medical bill into smaller portions that you can pay every month. A payment plan makes it easier for you to settle the cost without having to pay a hefty amount at once.

Making the Case to Your Insurer for an Out-of-Network Healthcare Service

If you’re planning to receive out-of-network care (or you’ve already received treatment and you’re looking to have your insurer cover the cost), you should be prepared to make a strong case with your insurance company. Most insurers will try to avoid covering the cost of an out-of-network service because the bill is often higher. Therefore, patients are faced with the burden of preparing a strong case, so they don’t end up having to settle hefty medical bills.

When preparing your case, begin by identifying the reason why you received (or you’re looking to receive) out-of-network care. If seeking pre-approval for a particular treatment, gather all necessary medical records and have the out-of-network provider prepare a supporting statement. The goal is to show that your provider of choice has training and experience that is lacking within your insurer’s network.

When you submit an application for pre-approval, don’t be surprised if the first request is denied. Most initial requests are not carefully considered by the insurance company. They may simply look to see if the caregiver is out-of-network and automatically issue a denial. However, when you file an appeal, a new team of both internal and external experts will review your application. They may comb through the details and consider why you’re seeking an out-of-network service. The same situation applies when seeking reimbursement after receiving out-of-network care. An appeal is often necessary to have your case closely reviewed (by the insurance company) for coverage.

Denials for Out-of-Network Coverage

As important as seeking out-of-network care can be in some cases, it’s not uncommon for health insurance companies to ultimately deny your claim. Even with a valid reason, you may still find yourself reading a denial letter and facing a large medical bill.

While some denials for coverage may be justified, other denials may simply be issued to protect the insurance company against high coverage costs. For example, if you received a denial after obtaining emergency care from an out-of-network provider, you have valid grounds for filing an appeal.

Here are other common reasons for preparing to file an appeal for an out-of-network denial.

  1. If you have a rare but serious condition that can only be treated by an out-of-network provider.
  2. If you recently switched to a new insurance provider, but you still rely on care from your previous doctor (who is now considered out-of-network)
  3. If your child is in college and can only receive care from out-of-network providers
  4. If you live in a remote area with no available in-network services

If you’re in need of urgent care and it can only be provided by an out-of-network service, your insurance company should cover all or part of the treatment cost. All insurers have a fiduciary duty to provide quality care to their patients in exchange for monthly premiums. Therefore, denials for out-of-network coverage should only be issued in legitimate circumstances.

For example, if you have a personal preference for a caregiver or you wish to receive additional services not included in your insurance plan, you may have to pay for the extra services yourself. However, receiving out-of-network care for a valid reason (such as emergency care) should result in coverage for the cost of treatment.

Help with Out-of-Network Coverage Denials Near Me

Being denied coverage for health insurance can be a very stressful experience. You may have received out-of-network care in response to an emergency, or you may be preparing an application for specialized care from an out-of-network doctor. Whichever the case, your insurance company should work with you to reasonably cover the cost of treatment.

Denials for out-of-network care are common because the insurer may not be willing to incur a high treatment cost. In addition, the insurance company may not receive discounted rates for care that you received from an out-of-network provider. It is for these reasons that an insurer may be motivated to deny your claim, even if it is valid.

Because you pay premiums on time and without fail every month, you deserve to receive quality care from your insurance company. The insurer can’t simply turn down a valid claim because coverage is not within their best interests. If you’ve received a denial for out-of-network treatment, you should immediately consult a lawyer to file an appeal.

Our law firm- Stop Health Insurance Denials- can represent you when filing an appeal for denied coverage. We will work with you to gather all supporting documents, justify your out-of-network treatment, and follow up with your insurer to receive the coverage you truly deserve.

Don’t struggle with a hefty out-of-network medical bill. Contact us today at 310-695-5241 and speak with one of our insurance attorneys.