I hate to admit that it wasn’t until recently that I fully understood the difference between in-network and out-of-network. I wish I could blame my parents for my ignorance, but every time I went to a doctor my parents diligently harassed me about whether or not I checked to see if the doctor was in-network.
In my defense, my parents coddled me a bit. They always saved me if I carelessly ended up with a bill from an out-of-network provider. They very literally, paid for my mistakes.
This changed, however, when I graduated from law school and became a “real adult”. The ink on my diploma wasn’t even dry before my parents promptly kicked me out of the cozy nest of financial backing I had grown accustomed to. It was time for me to fly.
Soon I was responsible for filing my own taxes, shelling out an ungodly amount for my tiny studio in Gramercy, and paying for my own insurance and medical bills. Although, now that I think about it, they still pay for my cell phone bill. Maybe they won’t notice until my next pay raise…
Up until this point, everything was going according to plan— I was busy “lawyering” and doing big girl things. Then Lyme happened. It wasn’t long before the medical bills piled up and these bills were from doctors who were “in-network”. But Lyme doesn’t make things easy—it is not for the weak.
Lyme handed me another twist: most LLMD’s are out-of-network or “don’t accept insurance”. I knew seeing an LLMD would cost me much more, but I desperately needed someone who knew, really knew, about Lyme.
Although I would pay almost anything to get my life and health back, I never stop getting sticker shock when I realize that just one office visit will run me $900 out-of-pocket. It doesn’t take too many visits before you are several thousand dollars deep in medical bills.
That’s when I realized I needed to get informed. What does out-of network really mean? Is that different from a doctor “not accepting insurance”?
To my understanding, insurance plans contract with a wide range of doctors, as well as specialists, hospitals, labs, radiology facilities and pharmacies (collectively referred to as “Providers”). Each of these providers has agreed to accept your insurance plan’s contracted rate as payment in full for services. These are “in-network” providers.
Thus, an out-of-network provider is a doctor who has not agreed to any set rate with your insurer, and may charge more. This means you may have higher co-pays, deductibles and other costs associated with out-of-network care. Further, your plan may not cover out-of-network care at all, leaving you to pay the full cost yourself.
This does not mean, however, that they won’t take your insurance information and bill the insurance company directly—it is very possible to go to a doctor and never realize they are out-of-network.
So, is out-of-network synonymous with “not accepting insurance”? Yes and no. Doctors who do not accept insurance are “out-of-network”, but they are distinct in that they will not submit the bill to the insurance provider.
It is important to note, however, that this does not prevent you from submitting the bill to the insurance company yourself.
In fact, it is critical that you do so as some insurance companies have deadlines for submitting bills for reimbursement. Under my policy, I must submit a “Health Claim Transmittal” form along with a copy of my “superbill” or “routing slip” (a detailed bill for your visit that includes procedure codes and a breakdown of the charges).
For good measure, I include a copy of my credit card receipt and write a letter that includes all of my identifying information, the date, and the list of enclosures. Including a letter, in my opinion, is important. It creates a record of correspondence with the insurance company regarding the claim. I plan to write more about that soon.
I also created labels with my name, member ID, group number, employer and date. I place one on every single page that I submit to the insurance company so there is no doubt about when a document is received.
Finally, I make a copy of EVERYTHING: my signed letter, the form, all of the bills and receipts. I also scan a version and keep it in a folder titled “Letters to Insurance Company”. To be clear, this does not mean the insurance company can’t or won’t deny a claim—I save appeals for another day.
But, they can’t deny a claim that you never submit. I know it’s really hard to work up the energy to deal with insurance reimbursements when you are sick. It’s overwhelming even for the average, healthy person.
Check to see if your employer offers services like "HealthAdvocate". These services, among other things, will coordinate your medical claims or work to reduce your medical bills.
Sometimes your employer has programs that aren’t widely publicized—do yourself a favor, shoot the HR/Benefits person an email and just ask.
In the end, asking a couple questions and submitting a couple forms could save you thousands of dollars. Money you could spend buying Paleo-friendly groceries, buying your friends a copy of “Under our Skin” or just going shopping to “treat yo self”!
Again, nothing in this post is intended to be legal advice. It’s just my thoughts as I go through this process myself. If you have any tips or advice, write me—I want to hear it all!