Mar 25

6 Good Reasons to go "Out Of Network"... and get your insurance to pay In Network rates

By Martine G. Brousse (nope, not AI)

"The Medical Bill Whisperer"

Patient Advocate, Certified Mediator

AdvimedPro

March 25, 2024

While we all understand that using an Out Of Network is not beneficial to our wallet, and in some cases not even covered by our insurance plan, there are 6 good reasons why it may be necessary to do so.

Should this happen, there are remedies to force the insurance to cover such services at the Higher In Network and therefore save you $.

A. Quick reminder: In vs Out

In Network is the highest level of pay from your insurance - and therefore preferred. It means that:

the provider has a contract ("participates") with your insurance or plan
the provider accepts the contractual allowance as "payment in full"
you get a discount (yeah!)
you cost is the lowest possible
you get other perks: easier access, faster appointments, preferred treatment, etc

2. Out of Network services are paid less, or not at all:

the provider has no contract with your plan or insurance
the provider expects payment for the total billed charges, from you if your insurance does pay in full
your ultimate cost is the highest as you receive no discount
you may have to pay up front, and try and get reimbursed yourself

B. The 6 main reasons to go "out of network":

You have no choice:

Emergency conditions may force you to visit to or be transported to an out of network ER or urgent care center
Even if the facility is In Network, the ER drs, specialists, and other professionals there who work on you are Out Of Network
OR you go to an In Network facility for non-emergency services (a planned surgery for example) but the specialists, hospitalists, therapists, anesthesiologists, radiologists, pathologists and other independent professionals are Out of Network.

2. Slow or No "Access to Care"

"Access to care" means the ability you have to get an appointment, receive necessary services, consult a physician, get to a hospital within a certain (quick) time limit, and without any undue delays that may negatively affect your health
Rural areas are often affected by a lack of medical professionals and hospitals, or by the long distances to get to them
There are federal guidelines as as well as many State requirements which insurance companies must comply with
Terms of policy will detail what constitutes - and violates - access to care requirements
If you cannot get an appointment fast enough, if the only Dr is not accepting new clients, if the waiting list is too long, your insurance either MUST find someone within the network to accommodate your needs, or pay an out of network provider to do so, especially if your health is at risk

3. "Continuation of Care"

This happens when your treating physician cancels their contract with your insurance/plan, and now becomes Out Of Network
OR you get a new insurance plan and your treating physician is not contracted with it
If you are undergoing a specific treatment (chemo for example) or if transfer of care would be detrimental or even severely injurious to your health, your insurance may be forced to continue paying the (now) OON provider at the higher In Network rate

4. Rare diseases/conditions

You may be forced to use an OON specialist if you have a rare disease, or number of complicated conditions which only a "super-specialist" can treat
If your PCP or In Network specialists are not trained, experienced or even knowledgeable, and the only expert is OON, your insurance may be forced to issue higher payments
If the In Network PCP or specialist decide to transfer your care because they lack the ability or expertise to treat you, you may be forced to be referred to an OON expert.

5. The In Network provider is unacceptable

Although more common in rural areas, or when only one choice of specialist is available, this has happened many times to clients of mine
The designated or only available In Network provider may have too many “one size fits all” specialties, and not specialized enough
Their location may be too far or inconvenient (more than 30 miles, or only through teledoc)
They may cater to a different population (only children or only women for example)
They may not speak your language
They may not understand your cultural or religious values (a female patient only wanting a female Dr)
They may just be learning about your disease or condition (learning from you!)
They may have provided subpar care, or been reprimanded by the Board, or even lost their license in another state
Their office, staff or they may not have met certain standards: uncleanliness (yes, it happens), lack of direct and prompt communications, inefficient or unsupportive staff, messy medical record keeping, extreme long wait while in office, rushed appointments, poor bedside manners, etc
Improper or unethical behavior by physician or staff
Improper or unethical billing practices

6. There's truly nobody In Network

You search through the directory and either there is no one available soon, who takes new patients, who treats your disease, who doesn't have a long waiting list
The directory is out of date, listing providers who have moved, retired or are no longer contracted.

C. What to do?

If you have had or are being forced to use Out of Network providers, there are remedies to get their services paid at the In Network rate:

1. No choice:

In case of Emergency anywhere: The federal No Surprise Act forces your insurance to pay Out Of Network providers (whether hospitals or professionals) at the higher In Network rate, and forces those providers to accept the In Network allowance as "payment in full". You may NOT be billed for the difference between the total charges billed and that allowance.
In case of Non-emergency services at an In Network hospital: The same Act forces your insurance to pay Out Of Network professional providers (anesthesiologists, radiologists, pathologists, surgeons etc) at the higher In Network rate, and forces those providers to accept the In Network allowance as "payment in full". You may NOT be billed for the difference between the total charges billed and that allowance.

2. Slow or no access to care

Check the terms of your policy. If no In Network provider can be found within the designated time frame, your insurance must pay an available OON provider at the higher rate. Although you might still be liable for the difference between the total billed amount and the In Network allowance (no contract = no discount), you would still save $ due to a larger insurance payment
Check your State's legislation or Dept of Insurance guidelines. If they cannot be met, your insurance must pay an available OON provider at the higher rate. Although you might still be liable for the difference between the total billed amount and the In Network allowance (no contract = no discount), you would still save $ due to a larger insurance payment
Use Google maps to show the distance to an In Network provider, or indicate how the office has no on ramp for your wheelchair, or has too limited office hours.
If the time driving there takes too long, or if your autistic child cannot stay in a car longer than a short while, document and use as an argument.

3. Continuation of Care

If you are undergoing a specific treatment such as chemo, your provider should file a "Continuation of Care" authorization request. Make it "expedited" if your next treatment is scheduled in less than 14 days. The treatment plan, current assessment, last visit notes, and other pertinent clinical info should be forwarded to the insurance, to show any potential detriment to your health if treatment was delayed or forced to be transferred.
If the treatment is ongoing but not life-saving (ABA therapy for an autistic child for example), you may have to file that request yourself. Documentation is key. Include same as above, plus any letter of support from other treating physicians. Explaining how a transfer of care now would lead to regression, loss of achievements, reversal of gains, poorer outcome will go a long way to get that approval
Such "in-for-out" authorizations cover OON services at the In Network rate, and will save you $ even if the provider can still bill you for the difference between the total amount billed and any insurance payments.

4. Rare diseases

You must prove 2 points in order to obtain an "in-for-Out" authorization and coverage for an expert: that there is no one with in the network able to treat you (or even see you) AND the OON provider is the only qualified, expert, available, trained to treat your special disease.
Include the CV of that expert, as well as confirmation that there is no one In Network (see below #6)
Document the expertise: specialized clinic, articles naming the person "THE expert",
Best would be a referral from your PPC or treating specialist, especially if they are In Network

5. The In Network choice is unacceptable

Documentation is key, whether pics of the messy office or unsanitary exam room (yup, seen them!), or documented numerous calls made without a response, lost reports or blood work, or improper handling of your care or case. In case of clinical error or unethical behavior, filing a complaint with the insurance would be one step, reporting it to the medical Board or even for malpractice are others.
Make a list of every in network provider in the directory you have contacted without results, or who should not be on that list. It is illegal for insurance companies to willfully neglect updating their provider lists
A provider's website details what kind of service or speciality they offer, and to which population. I often use such screenshots to prove a point: too general a practice, not experienced with the gender/age/health issue needed, etc.
On occasion I have used Yelp and other reviews/complaints to show how a provider was gathering many more complaints than accolades
Any financial or billing shenanigans should be reported as well. Ignorance and incompetence are one thing, willful or fraudulent practices another.

6. There truly is no one else

Again, you will need to show that there is no one In Network that can do the job, and that only the Out If Network provider can or could.
Best if you can get a referral from your PCP or treating MD
Use tips from "access to care" and "unacceptable provider" to pad your request for a special authorization.

A little research can go a long way to saving you $, as does auditing every Explanation of Benefit you receive from your insurance.

Emergency claims should pretty much always be In Network, as should professional charges at an In Network facility.

Call your insurance when in doubt, and consult Google in regards to State laws and standards. Using the terms of policy is a useful step toward success.

Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.