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How an Out-of-network Bill Becomes a Claim

posted by TrueNorth Employee Benefits on Tuesday, July 5, 2016

Out-of-network care can be very costly, but unexpected medical visits can sometimes occur. Here are the steps for how out-of-network coverage is provided during a medical visit.

Provider

The patient receives the treatment. The doctor then sends the bill to the insurance company (the address listed on the back of the patient's health plan ID card).

Bill

The bill for services is then presented to the insurance company. Payment responsibilities are calculated and divided between the patient and the insurance company. 

Insurance Company Payment / Explanation of Benefits

Insurance pays for its portion of the bill from the provider. A summary of charges and insurance payments is sent to the patient from the insurance company. 

Patient

Patient pays doctor's office for copayments, deductibles, and/or co-insurance that he or she is responsible for.

Going to an out-of-network provider will give you more choices, but an in-network provider is almost always less expensive and easier. The payment for covered services is sent directly to the network provider, which results in less work for you.

If you decide to go out of network voluntarily, there are several resources that can help you make the best financial decisions, such as www.fairhealthconsumer.org. This nonprofit is dedicated to helping consumers receive and estimate health care cost information. 

If possible, do your research on local providers that are covered by your insurance before any care is needed. 

Calling the physician directly and double-checking with your insurance carrier is the best way to ensure that the provider is in-network. If you are receiving surgery, make sure to ask if the service is completely in-network. Often, things such as anesthesia are not covered even though the primary physician is in-network. 

Staying in-network not only means less money out of your pocket - it's also easier.