What Is an In-Network Provider?

Do you have a favorite hair stylist—the one who always seems to get your cut just right? Or a personal trainer who knows just what it takes to get the most out of your time at the gym?

If you do, then you know how important it is to find professional care that works best for you. Why should it be any different when it comes to your health?

But when it comes to finding a doctor, hospital, pharmacy, or surgical center, though, it may not be as easy as waiting for your favorite chair to open up at the salon. This is because your health insurance plan has a network of physicians, clinics, hospitals, and the like. Your plan’s network makes it a lot easier—and a lot less expensive—for you to see some medical professionals instead of others. But why is this? And what does it really mean for a medical provider to be in-network?

Networks can be confusing. Let’s see if we can help demystify things. Here’s a quick rundown on all things networks: how they work, what it means for a provider to be in-network, and why understanding your network is such a key part of understanding your insurance coverage.

“What Is a Health Network?”

Broadly speaking, a network is a group of health care providers—including doctors, specialists, hospitals, labs, and pharmacies—that have a partnership with your health insurance company to be a part of your insurance plan.

These providers contract with insurance companies, agreeing to provide services to the members of the companies’ plans at a set rate, which is typically lower than the rates they would charge without a contract.

So, an in-network provider, also called a preferred provider or participating provider, is a medical professional who will offer service to all of the members of your plan, at a fixed rate set by an agreement with your insurance carrier.

Working With a Health Insurance Consultant Vs. Buying Direct

“What Are the Advantages of Staying In-Network?”

You may have heard that the best way to save money and get the most out of your health insurance plan is to stay in-network. This is because, when you stay in-network for medical care, you typically receive:

1.) More Predictable Costs

Health insurance companies prefer to contract with providers because this arrangement allows them to offer more controlled and predictable costs to plan members.

When a service provider is in-network, the medical professional agrees to accept the rate they agree upon with the insurance carrier as full payment. As a result, patients generally only have to pay their plan’s predictable out-of-pocket costs, including their coinsurance, copay, and deductible. (You can read more about out-of-pocket costs in our handy guide, available here.)

2.) Lower Payments

Generally speaking, patients will pay less for service from an in-network provider than an out-of-network provider, thanks to that contracted price.

We’ll dive into out-of-network providers in a second. For now, to help illustrate how this works, here’s an example, adapted from writer Christina LaMontagne’s great article over at NerdWallet.

Let’s say you go to an in-network doctor, and the total charge for service is $300. However, because your doctor has agreed to their negotiated rate with your insurance company, the actual charge is less—let’s say $250. From there, your plan will pay its agreed upon share. If that’s 70 percent, your plan will pay $175, leaving you with a final total expense of $75.

However, with an out-of-network provider, your final costs will go up. Why? If the charge is $300, there won’t be a network discount applied. Even if your plan pays the same percentage amount for out-of-network coverage as it does for in-network—in this case, 70 percent—the amount you pay will go up, since that percentage is based on the physician’s full rate. In this example, then, your cost for going to an out-of-network provider would be $90.

More importantly, many plans do not pay for out-of-pocket coverage, or they’ll pay a significantly smaller percentage of the cost. So, if your plan only covers 50 percent of out-of-pocket costs, say, you will be on the hook for paying a final bill of $150 yourself—twice what you’d pay for service for an in-network provider.

“What Happens If I Go Out of Network?”

An out-of-network provider is one who has not partnered with your plan. As a result, visiting an out-of-network provider for service is often more expensive and more complicated, for several reasons:

The provider’s rate may be higher.

Rather than agreeing to a negotiated rate, out-of-network providers set their own rates, which can be far higher. Out-of-network providers may also use a practice known as “balance billing,” and charge you for costs in addition to your insurer’s contribution and your copay/coinsurance.

Your health plan may pay less.

Many insurance plans pay for less of the total amount of the cost for out-of-network providers than for in-network. For example, a plan may cover 70 percent the costs of an in-network doctor’s visit, but only 50 percent for one out-of-network. Some plans only cover out-of-network care in the event of an emergency.

Your deductible may be higher.

Many plans have an out-of-network deductible that is different from the in-network deductible. Out-of-network deductibles are typically higher. This means you will have to pay more before your plan begins any cost-sharing measures for out-of-network care.

You may have to do more legwork.

Visiting an out-of-network provider may mean more time and paperwork for you, as you research and figure out factors like costs, coverage, and precertifications.

“How Do I Find Out Which Providers Are In-Network?”

To make sure that you’re getting the best possible rates and coverage, it’s important to know which providers are in-network, and which are not. This can sometimes be complicated, because some providers will accept your insurance coverage, without necessarily belonging to your plan.

To help determine which of your local doctors, specialists, labs, and offices are in-network, you can consult with your insurance carrier’s website. Most have a provider look-up tool or directory, so that you can see who belongs to your network before you book an appointment.

Your insurance card can also be an invaluable resource. Using the customer service number on your card, you can usually get in touch with someone from your insurance provider, to help determine if a doctor or pharmacy belongs to your network.

Better yet? What if you could confidently say “I Got a Guy” to answer any questions or manage concerns you have, for the life of your health insurance policy? That’s where Matt Peebles and the Enrollment Specialists can step in to help.

“Is There Anyone Who Can Help Me?”

Want to make sure your next plan includes as many of your favorite providers as possible? Want to have a guy you can call to find out which providers are in-network should something unexpected come up for yourself, your family, or your business? Matt Peebles is here and ready to help as your personal health care insurance consultant.

Matt is the founder and CEO of the Enrollment Specialists, and is recognized in the top 1 percent of health insurance brokers nationally.

When you work with Matt, he’ll sit down and truly get to know your unique wants and needs, so that he can design and customize the health insurance policy that’s right for you—making sure your costs are minimized while your coverage is at its peak.

Better yet, whenever you have any questions about your policy, need a go-between to work with the insurance company on your behalf, or require new insurance cards or documents, Matt is always just a quick phone call or email away.

Instead of having to waste your time with unhelpful chat rooms, anonymous call centers, or unruly insurance company websites, you can rest easy, knowing you’ve got a personal health insurance superhero who will always be able to swoop in and save the day. And remember—it will never cost you a cent to work with Matt and the Enrollment Specialist team, whether you’re shopping for a new plan or using him as your go-to guy down the road.

Have any more questions about networks, plans, or coverage options? Don’t hesitate to drop us a line today to get the conversation started.

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