Today we will try to dispel common misconceptions and settle fears regarding out-of-network providers and explain why you shouldn’t be so afraid of going to see one.
The first major misconception regarding out-of-network or non-participating providers is that they only accept patients willing and able to pay cash for the services they receive. Similarly, some people believe out-of-network physicians do not accept insurance at all. This is largely FALSE. Practices that do not accept insurance do not necessarily require that a patient pay completely out of pocket or with cash only. What it means is that your insurance plan needs to have out-of-network benefits if you hope to be reimbursed. So, let’s break this down a step further. All insurance plans have in-network or participating providers. This means that the provider or practice has signed an agreement with certain insurance companies stating that they will accept pre-negotiated rates for specific services rendered. Furthermore, they legally cannot bill the patient any more than their co-pay or coinsurance specifies once their deductible has been met. Only CERTAIN insurance plans have another, higher level known, most commonly, as out-of-network benefits. If you have this extra level of benefits, you can go to an out-of-network provider and then (usually once you meet a separate deductible) you will have coverage for these services. The level of coverage for out of network services is usually lower than services rendered in-network.
Now that we understand this basic concept of how in- and out-of-network benefits work within insurance plans, let’s look at why a provider may NOT choose to participate with insurance companies. Before I get in too deep with this explanation, I would like to make sure everyone understands something: physician charges and insurance reimbursement have become a convoluted system of two independent parties both trying to make money, as well as meet the common goal of serving their client or patient. So, please remember as you read this or anything else about physician fees, insurance reimbursement, etc. Having said that, I also believe that the first and ultimate goal of both parties is to help humanity. Nonetheless, financial pressures are real. Physicians are trying to run a business, feed their families, and provide a means of income for their employees. This is not a bad thing, actually. The financial elements of our American healthcare system has yielded the most sophisticated medical practices in the world. At the same time, our healthcare system is now seemingly suffering in many ways.
The problem with accepting pre-negotiated rates is that they don’t cover costs. Some out-of-network doctors bill their patients and leave the patients to deal with their insurance companies. We see this as unfair given that most patients are novices when it comes to insurance claims. We prefer to submit claims on behalf of our patients. We can explain our charges. This usually ends up benefitting the patient. Either way, the patient retains the right to argue the reimbursement rate if they are dissatisfied. We are happy and willing to work with patients in order to get them reimbursed at better rates.