How an Out-of-Network Bill Becomes a Claim

Out-of-network care can be incredibly expensive, but unexpected medical visits can sometimes happen. Here are the typical steps for how out-of-network coverage is provided during a medical visit:

1. Provider – The patient receives treatment and the doctor sends the bill to the insurance company.
2. Bill – The bill for services is presented to the insurance company. Payment responsibilities are calculated and divided between the insurance company and the patient.
3. Insurance Company Payment/Explanation of Benefits – Insurance pays for its portion of the bill from the provider. Insurance payments and a summary of charges is sent to the patient from the insurance company.
4. Patient – The patient pays the doctor’s office for copayments, deductibles, and/or coinsurance 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 easier and less expensive. The payment for covered services is sent directly to the network provider which means less work for you. Whenever possible, do your research on local providers that are covered by your insurance before any care is needed.

Double-checking with your insurance carrier and calling the physician’s office directly is the best way to ensure that the provider is in-network. If you are undergoing surgery, make sure to find out if the service is completely in-network. Things such as anesthesia are often not covered even though the primary physician is in-network.

Staying in-network not only means less money out of pocket – it’s easier!

We are here to help and provide guidance for any questions or concerns you may have, contact us!