The common advice given to people with health coverage is to make sure your doctor is in network.
Plans have IN and OUT of network coverage. Talking of PPO (Preferred Provider Organization) plans, your benefits are richer for the user in network vs. out of network. Consumers know they will have to pay more to providers that are not in the network of the insurance plan they are on.
A little noticed change could be coming to your plan for several major insurers are using rates based on Medicare fees to calculate payments for out-of-network providers. This could amount to lower payments to providers. The Medicare amounts are often a lot lower than what hospitals and doctors actually charge. So Providers may bill patients for the difference. What is more, this bill comes on top of the patients deductible and co-payments.
We need to check on providers when possible before having a procedure or test run. For example an in network hospital could have a doctor or specialist who is out of your network. If you are treated by this out of network provider, you will be bill accordingly.
If you get charged and did not see it coming you can appeal to the insurance company and also try going to the state Insurance regulator (Texas Department of Insurance -TDI) for help.
You can read more about “Out of Network Rates” from the Wall Street Journal, June 19th, 2011.
The FAIR Health website also offers an excellent Glossary of Common Health Reimbursement Terms. A link to this glossary will soon be added to our Resource page as well.
FAIR Health has launched FH™ Reimbursement 101 — a series of informational guides that use good old-fashioned “plain speak” to help consumers better understand the healthcare system and how to use it.
The following FAIR Health Videos offer easy to understand Out of Network explanations: