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Ask Christina: What Is the Difference Between In-Network and Out-Of-Network?

August 12, 2014
Health, Managing Health Insurance
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Question:

What is the difference between in-network and out-of-network? I know it’s more expensive to see a doctor who is out of my network, but why? How do I determine whether or not a given provider is in my network?

Answer:

“In-network” health care providers have contracted with your insurance company to accept certain negotiated (i.e., discounted) rates. You’re correct that you will typically pay less with an in-network provider. “Out-of-network” providers have not agreed to the discounted rates.

This is best explained with an example. Here’s a good one from Blue Cross Blue Shield of Michigan:


Say you go to a doctor that’s in-network and the total charge is $250. A discount is applied to that amount for our negotiated rate with the doctor. The discount is $75. Blue Cross Blue Shield of Michigan pays $140. You’ll have to pay the remainder, which is $35.

Now let’s say you go to a doctor that’s out-of-network. No discount is applied to the total charge. We still pay $140 but you’ll be responsible for the remainder, which is $110.


It’s often up to you to determine whether a given physician is in-network for your insurance plan, so make sure you ask the right questions. Keep in mind that accepting your insurance and being “in-network” are not necessarily the same thing. A physician may accept Humana, BlueCross BlueShield, UnitedHealthcare, Kaiser, etc. insurance, but that does not mean that he or she is an in-network provider for your plan with one of those insurance carriers. The best way to check is to call the customer service number located on your insurance card and verify a provider’s network status.

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