Getting sick or hurt is stressful enough. No one wants to compound that stressful experience with a nasty surprise medical bill in the mail. But it happens all too often. In this blog post you’ll learn how to avoid those nasty out-of-network fees.
How to Avoid Out-of-Network Fees
Many times, out-of-network fees occur because you enter a hospital that is in-network, but you’re treated by a physician who is not in your plan’s network.
Or their fees may simply be higher than what your health plan is willing to pay for that particular service.
When that happens, your insurance will pay them their maximum reasonable and customary amount (as they calculate it). And the doctor’s office will send you a bill for the difference – a practice called balance billing.
Here are some practical strategies to help you avoid these additional costs.
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The “No Surprises Act” Effect on Out-of-Network Fees
Since 2022, a federal law called the No Surprises Act effectively prohibits the practice of balance billing for those with traditional health insurance.
However, those without health insurance, and those who are enrolled in health sharing plans need to be more vigilant, as the law provides lesser protections.
To learn more about balance billing and the No Surprises Act, read our recent HSA For America Health and Wealth Newsletter.
Consider a Health Sharing Plan
Health sharing plans often have more relaxed network structures compared to traditional insurance plans.
This means members usually have more freedom to choose their healthcare providers without strictly defined network limitations.
When you are free to choose your own doctor, like you are with a health sharing plan, you don’t have to worry about in-network vs. out-of-network providers. Most health share plans let you use your benefits with any doctor.
However, they may not share the doctor’s entire bill. Even if you have met your Member Responsibility Amount for the year, they may not share amounts over and above the reasonable and customary amount in your area.
Where possible, it’s a good idea to get prior authorization from your health share plan before receiving services.
Additional Tips on Out-of-Network Fees
1.Check Your Plan’s Network Before Getting Care
Always review your plan’s network before seeking care.
This step will help ensure that the healthcare providers and facilities you choose will be automatically covered.
2.Use Patient Assistance Programs and Advocates
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- Patient Assistance Programs can provide financial help or guidance on how to manage healthcare costs effectively.
- Hospital Patient Advocates can offer insights and assistance in navigating your care options within the network.
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3.Ask for Cash Pricing
Hospitals and clinics are now required to provide transparent pricing on their websites.
Paying the cash price out-of-pocket for certain services can sometimes be less expensive than paying the out-of-network cost.
4.Submit an Out-of-Network Exception Request
Sometimes life takes a turn for the unexpected, such as when diagnosed with a rare medical condition, or if a natural disaster impacts your area.
In these unique circumstances you might need to access healthcare services from a provider outside of your network. You can submit an exception request to your insurance company so that you don’t have to pay the out-of-network fees.
5.Review Your Superbill
In cases where a healthcare provider is out-of-network, you are required to pay for the healthcare services at the time they are provided.
To file a claim with your insurance for these services, you need to collect detailed documentation of the care received. Providers compile the details of the services and your payments into what is known as a superbill.
If you receive a superbill for out-of-network services, it’s important to understand the process of getting it reimbursed. Keep detailed records and follow your insurer’s guidelines for submissions.
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Out-of-Network Fess Conclusion
The best way to avoid unexpected out-of-network costs is to understand the details of your health insurance plan, and look for alternative options.
For personalized guidance, connect with a Personal Benefits Manager who can help you take control of your healthcare expenses and make informed decisions.
Learn More: How Much Money Can Healthsharing Save? | Who Qualifies for Health Insurance Subsidies? | Why Health Insurance Costs Are Going Up So Much (And What You Can Do About It)
