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Tips to minimize out-of-network fees Posted: September 13th, 2010

By Megg Mueller

Tips to minimize out-of-network fees

Paying for doctor visits and hospital stays, even with a health insurance plan, can cost a pretty penny. But if you go out of your plan's network for care, you could be in for a major shock. You may end up with a medical bill that is much more than your co-pay or you could even be responsible for the entire amount.

Going out-of-network usually happens for a couple of reasons. One, you might choose to see a specialist that is not in your health insurance plan's network of preferred providers, or two, you could need emergency care and be taken to a facility that is not in your network. If you choose to see a provider that isn't part of your plan's network, you will pay more for services, but there are still steps you can take to keep costs down.

Choosing the provider

Obviously, an in-network physician is going to cost you less, as your insurance and that doctor have agreed-upon fees which your insurance covers. But if you want to choose another provider that is out-of-network, make sure you know what your plan covers. This way, you can mitigate expenses or avoid procedures or physicians you'd have to pay for entirely out of pocket. You could also:

  • Ask your doctor or his billing staff how much the procedure or test you need may cost.
  • Learn what "reasonable and customary" means to your insurance provider. Some plans, particularly preferred provider organization (PPO) plans, often pay a portion of out-of-network fees so call your insurance company and ask how much they cover. According to Families USA, an advocacy group, if your insurance company won't reveal what they are willing to pay, remind them of a Department of Labor advisory notice that says patients have the right to this information.
  • Negotiate if you need to. If your insurance plan pays considerably less than your bill, see if your doctor is willing to adjust his fee to match what your plan pays. If not, ask for a discount on the portion you are required to pay.

Emergencies happen

If you find yourself in an emergency situation where you require hospitalization or acute care, the last thing you may be thinking about is the cost of treatment. But there is a little-known factor that you should keep in mind: even if the hospital or care facility where you receive treatment is covered under your plan, it's possible some doctors are not. From anesthesiologists or radiologists you might never see, the doctors who care for you all bill separately for their services. If you have the ability to ask before treatment, try to verify that these specialists are in your health insurance plan's network.

If you find yourself faced with a bill for emergency treatment that isn't covered under your insurance plan, start making calls. Start with your insurance company, and appeal its refusal to pay--you can appeal any denial. Be ready to prove the treatment was an emergency, and not something you could have done with an in-network provider. Contact your doctor or doctors and their billing managers for assistance. If that doesn't work, contact your state's insurance department or attorney general or hire a medical billing advocate to assist with your case. These advocates generally charge a percentage of the money they help you save.