In-Network vs. Out-of-Network: Why Going to the "Wrong" Doctor Can Cost You
Two doctors can do the exact same test. One visit might cost you $120. The other might cost you $1,500. The difference might be whether the doctor is in-network or out-of-network.
What is a network?
Your insurance company makes deals with certain doctors, hospitals and labs. These places agree to charge lower prices to you. This group is called your plan's network.
In-network means the doctor has a deal with your insurance. You get the lower price.
Out-of-network means the doctor has no deal with your insurance. Prices are higher, and your insurance may pay less or nothing at all.
Think of it like a store card. Shop at the stores on the list, and you get the discount. Shop somewhere else, and you pay full price.
Let's look at Maria's MRI
Maria needs an MRI. She has already met her deductible, so she pays 20% of in-network costs.
Clinic's full price
In-network clinic: $1,800
Out-of-network clinic: $1,800
Price after insurance deal
In-network clinic: $600
Out-of-network clinic: No deal
Insurance pays
In-network clinic: $480
Out-of-network clinic: $0
Maria pays
In-network clinic: $120
Out-of-network clinic: $1,800
Same MRI, but a $1,680 difference for Maria. That's the cost of going out-of-network.
Why out-of-network costs so much more
No deal on price. The doctor can charge their full price.
Insurance pays less, or nothing. Many HMO and EPO plans pay nothing for out-of-network care, except in emergencies. PPO plans usually pay some, but much less than in-network care.
It may not count toward your deductible. Some plans have a separate, bigger deductible for out-of-network care.
You can get a surprise bill. An out-of-network doctor may bill you for the part insurance didn't pay. This is called balance billing.
Some protection in emergencies
A federal law called the No Surprises Act helps protect you:
In an emergency, you can’t be balance billed, even at an out-of-network hospital. You pay your normal in-network share, like your co-pay or your coinsurance. That amount counts towards your deductible and out-of-pocket maximum.
At an in-network hospital, an out-of-network doctor your didn’t pick, like an anesthesiologist, generally can’t balance bill you either.
How to stay in-network
Use your insurance website or app to search for doctors in your network.
Call the doctor's office. Ask, "Do you take my plan?" Say your plan's full name, not just the insurance company's name.
Check every time. Doctors can join or leave networks during the year.
Ask about the other people on your care team. Labs, X-ray offices and some doctors at a hospital might not be in your network.
Key takeaways
In-network doctors have a price deal with your insurance. Out-of-network doctors don't.
Out-of-network care can cost much more, and some plans won't pay for it at all.
Always check that a doctor is in-network before you go.
