Health Insurance: In-Network Vs. Out-Of-Network

July 11, 2012

Let’s say you have a terrible sinus infection and you absolutely can’t take it anymore. You finally break down and schedule an appoint with your primary care doctor. Since this condition is relatively mild compared to other medical situations, chances are you have already done the necessary homework to find out if your doctor is in your insurance company's network or not. By doing so you have saved yourself a couple bucks and maximize your health insurance benefits.

On average staying in-network will save you 50-60 percent on medical services. On minor claims like doctors office visit and routine antibiotic medication the monetary value is hardly a financial emergency. However, if you ever find yourself in an actual medical emergency there are a few important questions to ask after the dust settles to limit the financial damage.

What Happens During an Emergency?

Let’s say you are on vacation in Disney World and just as you walk off Space Mountain you are greeted with severe abdominal pain. You tough it out and make it to dinner at Cinderella’s Royal Table. Halfway through your meal you collapse due to the extreme pain. You are rushed to the nearest hospital for an emergency appendectomy. Due to the sudden and unexpected nature of this medical emergency it is very unlikely you took the time when planning your trip to map out local hospitals that were in-network for your health insurance. Don’t worry, most health insurance plans will cover all emergency service as an in-network expense. So now you are in your room recovering from the operation just finally starting figure out what happened. This is when you are going to want to find out if you ended up at a location that accepts your insurance.

If you find yourself at a hospital that is not in-network, once all emergency services have been completed it is probably in your best interest to ask to be transferred to a nearby facility that is. This simple step, while not the most comfortable or ideal, can save you thousands of dollars and countless hours of your time.

Why You Don't Want to Go Out-of-Network

If you were to stay at the out-of-network hospital, you would run up charges that far exceed your out-of-network deductible. By doing so your insurance company will write a check for a large portion of the medical bills, however there could still be a tidy sum of money left unaccounted for that the hospital could try and recover from you. That means you have to spend countless hours on the phone negotiating these remaining bills with the hospital.

By transferring to an in-network facility all your medical claims will be applied to your in-network deductible and paid without any hassle. Most of the time your in-network deductible is half the amount of your out-of-network deductible.

I know just the thought of having to address an issue like this will rub most people the wrong way. However, Health insurance networks are setup for a reason, they exist to offer medical care at a discounted rate to those who are encouraged to seek treatment from the participating facilities.

The truth of the matter is, until doctors and hospitals start working for free medical treatment will cost money, a lot of it. Until then, it is important that with the help of your insurance agent you manage those costs the best you can.