“Out-of-network” refers to physicians, hospitals, and other healthcare providers who are not contracted with a particular health insurance plan. Depending on the health plan, healthcare received from out-of-network providers may require higher out-of-pocket charges for the plan enrollee or the healthcare may not be covered by insurance plan at all.
Sometimes health insurance plan enrollees do not realize that the care they are receiving comes from an out-of-network health care provider. This can happen for numerous reasons. For example, a health plan enrollee might go to an in-network hospital for a service but the doctor from whom the care is received is out-of-network. Other times, a health care provider may have once been in-network but later on left the health insurance plan’s provider network. The resulting medical bills from these scenarios, with their high uncovered costs, are sometimes referred to as a “surprise medical bills.” In a surprise medical bill scenario, the health plan enrollee may have to battle the insurance provider if he or she wants assistance in paying the medical bill. Moreover, there is no guarantee that the surprise medical bill dispute will resolve in the favor of the health plan enrollee.
Given the prospect for surprise medical bills, it is important for a consumer to confirm a health care provider’s participation in the enrollee’s health plan network prior to receiving medical care.