What is the difference between in-network and out-of-network?

What is the difference between in-network and out-of-network?
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#1

What is the difference between in-network and out-of-network?


#2

"In-network" healthcare providers have contracted with your insurance company to accept certain negotiated (discounted) rates. You typically will pay less with an in-network provider. "Out-of-network" providers have not agreed to the discounted rates.

Here's an example from the Blue Cross Blue Shield of Michigan web site:

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.


#3

Larry McClanahan's answer is spot on. Not only does each insurance carrier have a group (aka "network") of providers who have agreed to accept a negotiated rate for their services, an insurance carrier can have different groups or networks that are "in-network" depending on the specific plan selected with the insurance carrier as well. 

Keep in mind just because Dr. Smith accepts Humana, BlueCross BlueShield, UnitedHealthcare, Kaiser, etc. insurance does NOT mean Dr. Smith is an in-network provider for your plan with one of those insurance carriers. Accepting insurance and being "in-network" may not be mutually exclusive. The best way to check is to call the customer service number located on your insurance card and verify a providers network status.

If you visit a medical provider who "accepts" your insurance, but they are not a "participating" or "in-network" provider with your insurance plan, the medical provider can then "balance bill" you for the amount your insurance carrier didn't cover.  Whereas an "in-network" provider can not charge you for more than your insurance carrier says you owe for the service provided.  In-network providers are contractually obligated to accept a negotiated fee schedule; Out-of Network providers may take insurance but they can charge you whatever price they deem fit. 


#4

If the doctor, hospital or health care facility you visit is part of your insurance company’s network, you’ll get your health care at lower prices. But if you go out of your network for health care, it can become a lot more expensive and they can balance bill you for the full charge amount.


#5

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