What Happens if You Go Out of Network for Care?

Today | 4 min read

Key Takeaways

Health insurance networks are built through contracts between insurers and health care providers, and these agreements determine how much a hospital or doctor will be paid for services.
When providers are in your network, that means they’ve agreed to negotiated rates for care with your insurance provider.
When a provider is out of network, your plan may cover a smaller share of the cost, or in some cases, none at all.
Several situations can cause your health care provider, specialist or go-to hospital to leave your insurance network. Most involve changes to contracts, employment or insurance plans.

Health insurance networks might not be something you think about much – until something changes. When something does change – which is covered in detail below – you need to know your options, so you can make the necessary adjustment to avoid a lapse in care.

If your doctor or hospital ends up outside of your plan’s network, the first question you’ll ask yourself is “what does this mean for my care and costs?” The short answer is you may still be able to receive care from your current doctor, but it could cost more.

Network changes can feel stressful, especially if they involve a provider you trust. But understanding how networks work can help you make informed decisions about your care.

What does it mean when a provider is in network?

Health insurance networks are built through contracts between insurers and health care providers. These agreements determine how much a hospital or doctor will be paid for services. When providers are in your network, that means they’ve agreed to negotiated rates for care with your insurance provider – that rates are usually lower than the provider’s standard price – and have agreed to your insurer’s allowable amount for services. In health insurance, the allowable amount is the maximum price an insurer agrees to pay for a covered health care service when you see an in-network provider.

For example, a doctor may charge $150 for a service, but your insurance provider’s allowable amount may be $90. As a member receiving in-network care in this scenario, you would save $60 on the service. You’ll see these savings listed as a discount on your claims and explanation of benefits (EOB).

How does out-of-network pricing work?

When a provider is out of network, there is no contract in place with your insurer. That means several things can happen if you seek care from this provider:

Your plan may cover a smaller share of the cost, or in some cases, none at all.
You may have a higher deductible or coinsurance for seeking services from this out-of-network provider.
The provider may charge the difference between their price and what the plan pays, a practice known as balance billing.

In other words, your share of a theoretical bill may be calculated from a higher starting price, compared to a provider that is in your network

This is one reason insurers encourage members to stay in network whenever possible. In-network providers have agreed to those negotiated rates, which helps lower costs for both members and the overall health plan.

Emergency care is typically treated differently. If you have a medical emergency, most plans cover the care at in-network cost-sharing levels regardless of where you receive treatment.

Additionally, while individuals with Preferred Provider Organization (PPO) plans will notice “out of network” references in their EOB and on their member account, those with Health Maintenance Organization (HMO) select from a list of “participating” or “nonparticipating” providers.

What events may cause a doctor to go out of network?

Several situations can cause your health care provider, specialist or go-to hospital to leave your insurance network. Most involve changes to contracts, employment or insurance plans. Examples include:

Contract negotiations break down between the insurer and provider
Your provider joins a different health system
Your insurance plan changes
The provider stops accepting your insurance, possibly due to reimbursement disagreements
Your plan’s network structure changes or your provider narrows its list of available networks

How to keep your doctor if your network changes

If your doctor or hospital leaves your network, you still have options.

You should first check whether your plan offers out-of-network coverage. Many PPO plans provide some level of coverage outside the network, although the out-of-pocket costs may be higher.

You should also either call your provider’s office. Sometimes physicians practice at multiple hospitals or locations, and one of those sites may still be in network with your plan.

You can also use tools available through your member account to explore alternatives. Blue Cross Blue Shield of Michigan members can use the Find a Doctor tool to search for in-network providers and compare care options. If you are in the middle of treatment – such as pregnancy, cancer care or recovery from surgery – your plan may offer continuity-of-care options that allow you to continue seeing your doctor for a limited period of time.

Provider networks are large and constantly evolving. As the largest health insurer in Michigan, Blue Cross plans include thousands of physicians and hospitals across the state, giving members access to care statewide. Our goal is always the same – we want to help members access high-quality care while keeping health care costs as affordable as possible.

If you’re unsure about your coverage or what a network change means for you, it’s best to review your EOB or call the customer service number on the back of your member ID card.

Learn more about what Blue Cross is doing to address health care affordability at bcbsm.mibluedaily.com/affordability.

Photo credit: Getty Images

Keep reading: