In Network v. Out of Network - What You Need to Know!


By: Madeline Inskeep

Two of the key phrases that patients hear when dealing with medical insurance or choosing a provider are “in network” and “out of network.” But what do those phrases mean? Do they really matter? 

They absolutely do! When it comes to medical bills and health insurance, knowing the difference between “in network” and “out of network” can have a huge impact on what you pay! 

“In Network” - What does it mean? 

Your health insurance plan has a list of healthcare providers that are “in their network,” or contracted – meaning they have a partnership with your insurance company. If you visit a doctor who is “in network” with your health insurance, your out-of-pocket costs are likely to be lower than if you visited a healthcare service that was not contracted, or in your insurance’s network. One reason for the lower costs is that for many health insurance plans, deductibles are lower for “in network” providers. Another reason is that balance billing generally does not happen with “in network” providers.

Paw Tip: the RexPay app enables you to view at a glance your insurance plan’s deductible and out of pocket maximums for “in network” v. “out of network” providers, assisting you in awareness and budgeting!

“Out of Network” – Yay or Nay? 

An “out of network” provider is a medical service that is not contracted, or in partnership, with your insurance plan. Oftentimes, because there is no standing agreement between the doctor and your insurance company, this means that the bills will cost more, both for you and your insurance company! Deductibles and out of pocket maximums are often higher for out of network providers, depending on the type of plan you have. It’s good to keep in mind, however, going to an out-of-network provider is sometimes unavoidable, like in the event of an emergency, or if you need a highly specialized doctor.  If you know in advance you will have to see an “out of network” provider, try to find out the costs ahead of time, and begin to budget accordingly.

“How can I tell if my provider is in-network?” 

If you’re still looking for the right health insurance plan for you, check the insurance company’s list of contracted providers, and ensure that it includes the kinds of practices your looking for. 

However, if you already have an insurance plan and are trying to see if your medical provider is “in network,” the first step is always to ask your insurance company. It’s good to do this before you visit the doctor. Your health insurance plan should provide a list of contracted providers.  

  1. First, call the number on your insurance card. Be sure you have your name, ID number and birth date information handy!  

  2. Once connected, choose to speak with your insurance’s Eligibility and Benefits department. Ask them if your provider is in network – you will need your medical  provider’s name, location, and phone number.   

  3. It’s also important to specifically ask about your provider, their facility, and your plan. Sometimes a provider may be “in network,” but their facility – i.e. a hospital or doctor’s office - may not be. That means you could see the same doctor at one location and pay “in network costs,” and then see the same doctor at another location, but be billed astronomically more. Similarly, make sure you specify your specific insurance plan, not just your insurance company, because the same provider could have a contract with one type of plan but not another.

The “in network” vs. “out of network” question can be a little daunting. Hopefully this breakdown helps you to understand the basics. The most important takeaway is to try to find out in advance what relationship your provider has with your insurance plan, and understand what that means for you financially.