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Navigating In-Network and Out-of-Network Charges

By James LaCorte | April 5, 2021 | Insurance Education

Whether you’re signing up for a health plan, searching for a doctor or prescription or just checking to see if you owe anything, the terms “in-network” and “out-of-network” are bound to pop up. And sooner than you might expect.

Knowing your insurance plan network is important because most of the time, there’s a difference in your costs between in-network and out-of-network. Over time, these costs can add up.

When selecting a plan during open enrollment, network access is one of your most important considerations. If you’re using existing benefits, your choice of a particular doctor, pharmacy or hospital can make a big difference in the cost, and maybe even the quality of services you receive.

What to Look For

Let’s sort it out in a little more detail.

  • Doctors don’t generally get the full cost of their services.
  • Your insurance negotiates a lower rate for you from your doctor.
  • The doctor joins your insurance company’s network of health care providers and agrees to charge less so you pay less. This is called being in network.
  • If you choose a doctor who is out-of-network, and not a partner with your insurer, you may have to pay part or all of the bill yourself.

There are many doctors and hospitals out there. And as part of our efforts to keep costs down, Blue Cross and Blue Shield of North Carolina works closely with many hospitals and physicians to help get you access to quality, affordable care, when you need it.

When you use an in-network provider, you’ll benefit by:

  • Gaining access to our discounted rates that often result in lower costs for you
  • Paying a lower deductible, meaning the amount you must pay before your insurance begins to pay [1]
  • Paying lower out-of-pocket costs, meaning any medical payments other than the insurance premium you are responsible for and for which you won’t be reimbursed [2]
  • Having preventive services that are covered at no cost to you [3]

Here’s an example: If you go to an in-network and have a $20 copayment, we pay the rest. The doctor’s actual charges might be, say, $150. But if you went to a doctor out of your plan’s network, your share of the cost will be much higher.

Surprised Billing Shocker

When we talk about in and out of network, it is important to warn you about surprise billing. This is when certain provider groups practicing at in-network hospitals stay out-of-network. This is generally done when providers know patients have no choice but to see them for care: for example, the emergency room or your anesthesiologist during surgery. Just because you are at an in-network hospital, that doesn’t mean the doctor seeing you will be in-network.

To avoid surprise billing, check with the provider(s) and hospitals on who will be giving you care and if they are in-network.  Here is more details about surprise billing.

The Bottom Line

Whenever you’re facing surgery or any health issue, it’s always a good idea to check on the status of your provider(s) before you receive care. And of course, if you’re facing a medical emergency, visit the nearest urgent care center or emergency department. It’s a good idea to get familiar with our guidance on whether to visit the ER or go to urgent care.

If you’re curious whether your doctor is in-network or not, you can use our ’find a doctor’ tool online. Blue Cross NC offers multiple types of products that are served by several different provider networks, so it’s important to be specific.

[1] If your plan has copays for certain services, you may not be required to meet your deductible first.

[2] This is true for NGF and ACA plans, but Grandfathered (GF) and Transitional (TR) plans still can have copays that aren’t required to be applied to the member’s Out of Pocket Limit.

[3] This does not apply to Grandfathered (GF) plans.