These two phrases decide a lot about what you pay, and almost nobody explains them properly.
What a network is
An insurance company signs contracts with doctors, practices and hospitals, agreeing what it will pay them for each kind of visit or procedure. The group of providers who have signed is that plan's network.
A provider who has signed is in network. One who has not is out of network.
Being in network is not a quality judgment in either direction. It is a commercial arrangement.
Why it changes what you pay
When you see someone in network, the price has already been negotiated. You pay your share of that agreed price, usually a copay or a percentage, and your insurer pays the rest.
Out of network, there is no agreed price. Your plan may cover a smaller share, or none at all, and you can be billed for the remainder. Out-of-network spending also often counts towards a separate, higher deductible, so it does not help you reach the limit you were expecting.
The gap between the two is frequently several times over, not a few dollars.
The three things worth knowing
- The plan matters more than the insurer. One company can offer several plans with different networks. "I have [insurer]" does not answer the question. The plan name does.
- Networks change. Contracts are renegotiated, and providers join and leave. Being in network last year does not guarantee it this year.
- Check before, not after. Two minutes on the phone before an appointment is worth considerably more than an hour arguing about a bill afterwards.
How to check, properly
- Call the number on the back of your insurance card.
- Give the exact plan name and your member ID, not just the insurer.
- Ask about both the doctor and the facility, since they can differ.
- Ask for a reference number for the call.
- Then ask the practice to check too. Both sides checking catches most mistakes.
A note on emergencies
Federal protections limit what you can be billed for most emergency care, even out of network. Never delay emergency care to work out whether somewhere is in network. Call 911 for chest pressure lasting more than a few minutes, sudden severe breathlessness, or sudden weakness, numbness or trouble speaking.
Quick answers
My doctor is in network but the hospital isn't. What happens?
You can end up with bills from both, treated differently. Always check both, and ask your plan what happens if one is in network and the other is not.
Does out-of-network spending count towards my deductible?
Often it counts towards a separate out-of-network deductible, which is usually higher. Ask your plan for both figures.
How do I find out which plans a practice participates in?
Most list them on their website. Still confirm with your insurer, because they hold the definitive answer for your particular plan.
We can check it with you
If you are not sure whether we are in network for your plan, call (239) 415-4900 and we will look it up with you before you book. We can usually see new patients within 1 to 2 days, pending insurance approval.
If your current cardiologist is leaving your network, see what to do next.
This page is general information about how insurance works. It is not advice about your own plan. Your insurer holds the definitive answer for your coverage.
Source: Centers for Medicare & Medicaid Services, No Surprises Act consumer protections.
