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- You’ll probably have to meet a separate deductible before benefits are payable for out-of-network care. There may be exceptions in a true medical emergency.
- An out-of-network provider’s charges are almost always higher than in-network, since there is no discount arrangement.
- Since out-of-network benefits paid by your plan are lower, you’ll pay a higher percentage of those already-higher charges. There may be exceptions in a true medical emergency.
- In addition, you may have to pay any charges in excess of the usual and customary (U&C) or reasonable and customary (R&C) amount.
- These are the amounts your plan determines to be typical and/or acceptable, based on what providers in a given geographic area usually charge. Some providers charge more than the U&C or R&C amount, others charge less. If you go out-of-network and face excess charges, you may be able to negotiate with your provider to reduce your balance due. One resource to check out: www.mymedicalcontrol.com
- Amounts you pay for out-of-network care usually don’t count toward your in-network deductible or out-of-pocket maximum.
- Amounts you pay for out-of-network care can be reimbursed from an FSA (flexible spending account) or HSA (health savings account).
- Some doctors who practice at in-network hospitals may be out-of-network providers. For example, the radiologist or pathologist may be independent of the hospital and bill you separately. Just because you are at an in-network facility doesn’t guarantee all doctors working there are in-network. If you charged higher, out-of-network rates, contact your benefits representative. In some cases - but not always - they may be able to negotiate on your behalf.
- Even at an in-network office visit, the doctor may use an out-of-network lab. Ask your doctor which lab service he or she uses, so you can call your plan and find out whether it’s in-network. If it isn’t, ask your doctor if you can have a prescription for the needed lab tests, which you can then take to an in-network lab.
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