What Are In-Network and Out-of-Network Providers?
Sometimes your health plan requires that you only visit their own network of providers. What is an in-network provider and how to find the right healthcare professionals?
Published January 22, 2021.
A network of providers is a group of medical and healthcare providers who are contracted by your health insurance company to assist the policyholders with their medical and health needs, at a negotiated rate.
In-network providers vs. out-of-network providers
In-network providers – whether doctors, healthcare professionals, or medical facilities – have entered an agreement with your insurance company to provide medical and health care to the policyholders at discounted rates. They are also called network providers, or sometimes preferred providers.
Generally, your health insurance works directly with the network providers to negotiate the rates and types of services available to policyholders. This not only brings premiums down for you but also provides the health providers with consistent work and business relationships. You will typically pay less with an in-network provider.
Out-of-network providers are healthcare professionals who do not have any contracts nor agreements with your insurance company. Be aware that using out-of-network providers can be costly and may not be covered by your health insurance plan, except in the case of a medical emergency.
Health plans using in-network providers
Most health plans use in-network providers.
HMOs (Health Maintenance Organization) usually limits your health insurance coverage to their network of providers. You will not be covered for any out-of-network medical care, except for emergencies. With an HMO, you would typically only visit your primary care physician (PCP) and need a referral to other in-network providers. If you choose or need to receive care from a doctor or hospital out of your network, you may not be covered by your insurance and you could have to pay most or all the costs yourself.
Similarly to HMOS, PPOs give you access to a network of preferred providers, which you can visit without referral and at lower cost: usually, your insurance company will have contracts with these in-network providers and agreed-upon rates for specific types of services. A PPO (Preferred Provider Organization) plan also lets you see out-of-network providers, but you will likely pay more for the care received: there is no set fee for these providers’ services and even if your insurance covers part of the invoice, some of the costs will be passed on to you. Frequently, the best way to avoid this is to use network providers only.
When you need care, it is important to follow the procedures provided to you by your health insurance company. With PPOs, you can see any healthcare provider and do not need a referral. This is highly convenient, but you might end up with unexpected medical bills if you unknowingly choose out-of-network providers. While it is sometimes frustrating working within these rules, it keeps costs down for you and your health insurance company. With both plans, be sure to verify who is in your network so as not to make any costly mistakes when it comes to your healthcare.
How to find an in-network provider
You can figure out what providers are in your network in a variety of ways.
Usually, your health insurance company will provide information on your local healthcare network and share a directory of Primary Care Physicians and in-network providers. Health insurance companies want you to use their network providers and typically have that information ready for you.
You can also call the individual healthcare provider that you plan to see, and simply ask. Healthcare providers typically have lists of networks that they work directly with and can provide you with the information that you need.
If you have any doubts or questions about how your individual network works, contact your health insurance company or speak with a health insurance agent you trust.