Any particular encounter you or your child has with a health system can involve several providers—each of whom might be in- or out-of-network.
In-network (or preferred) providers are groups of doctors and other care providers that your insurance company has agreed to pay at a contracted rate. Though there are some exceptions, if you choose to see doctors that are outside of this list (out-of-network), the insurance company will either pay less or not pay anything for services you receive.
Example 1: At an office visit, the doctor may order blood work and x-rays. The doctor may be in network, but the lab to which the blood work is sent may not be. The hospital or other facility performing the x-rays may be in network, but the radiologist interpreting the x-rays may not be.
Example 2: A hospital stay for surgery might involve separate bills from the hospital, surgeon, anesthesiologist, radiologist, pathologist, and other specialists―all of whom might be in or out of network. Because each of these different medical providers generates a separate charge for their work, a family might receive eight or more separate bills for a complicated hospital stay.
It is important for you to understand these terms and how they can affect insurance reimbursement and additional out-of-pocket expenses you might have to pay.
Frequently Asked Questions (FAQs)
Why do insurance companies have "networks"?
Insurance companies maintain networks primarily to control and predict costs. Rather than pay a doctor's bill for a particular service, insurance companies create networks in which doctors agree to accept a reduced payment (the "allowable payment"). Because insurance companies discourage their members from going out of network, doctors agree to the reduced payment to get into the network. Network contracts may have other requirements or restrictions on their participating providers.
Can a pediatrician be a member of different networks?
One insurance company may operate several networks, and a pediatrician might be in network with none, some, or all of them. Some networks might be operated on behalf of a government line of business, such as Medicaid, SCHIP, or Medicare. Other networks might take one of the following forms:
Can my child see doctors and other providers not participating in my health plan?
While it is possible to get a referral outside of your plan, managed care plans don't often approve care from out-of-network doctors or other providers, such as clinical psychologists, physical therapists, etc. You may need to pay for all or some of the charges by an out-of-network provider. Check your plan for details. There are preferred provider organizations (PPOs) that enable you to see providers outside of your plan, but additional fees will be required.
Will my child's health care be paid for if he is injured when we are out of town?
Note: Exemptions may be made for college students attending school away from home.
What is a "true emergency"?
Most managed care plans define a "true medical emergency" as a sudden, unexplained or possibly life-threatening medical situation, or a very severe illness or injury for which you do not have time to call your pediatrician.
Most plans will pay for emergency room care in a true emergency. Follow-up care (such as removing stitch es) should be done in your pediatrician's office. Your plan will not pay for follow-up care done in the emergency room.