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  • HooPayz

Out of Network, Out of Luck?

You may not realize it, but your health insurance plan has a specific network for physicians, hospitals, pharmacies, and more. A network is simply a group of hospitals, doctors, pharmacies, MRI centers, etc. that your insurance company has contracted with to provide you care. By choosing in-network care, you’re automatically saving yourself money.

Choose any of these easy ways to find out who is in your network:

  1. Visit your health insurance company’s website.

  2. Call your health insurance company and ask about a specific provider.

  3. Call the doctor, pharmacy, or hospital and ask if they accept your insurance.

4 Common Out-of-Network Scenarios Explained

The four scenarios below are common, and can end up costing you thousands of dollars. Let us walk you through what to do, and how to save money in each situation.


1. Your Doctor Refers You to a Hip Specialist

Just the other day we were talking to a HooPayz member who said her primary care doctor wanted her to see a surgeon about her hip. She went to the surgeon, and ended up having hip replacement surgery. Once the bills started coming in, she was shocked to see the charges were for an out-of-network doctor!

How could that be? Her primary care doctor told her to see THIS surgeon. There are any number of reasons why her doctor recommended this surgeon, but he wasn’t in John’s network. Doctors are often unaware of who is included in which networks.

HOT Tip: ALWAYS check to see if a specialist or surgeon is in your network, even if your doctor referred or recommended them. If you do end up choosing an out-of-network provider by mistake, call your insurance company and try to appeal.

2. Your Doctor Orders an MRI

Let’s say your doctor or specialist wants you to get an MRI on your shoulder. He will send an order (a written or electronic request for a procedure sent to a facility by your doctor) to an MRI center. You get your MRI, then start receiving the bills for an out-of-network facility! Even if your doctor sent orders to a specific facility, it doesn’t mean you have to go there. Always check to make sure the facility accepts your insurance.

If you do decide to go to a facility that’s different than the one your doctor sent the orders to, make sure you call your doctor back and have him send the order to the facility you chose.

HOT Tips: Always call either the facility or your insurance company to make sure they accept your insurance. Also, choose a non-hospital based MRI, X-ray center, etc. for a lower price. We have a pricing transparency tool that helps you pick a high-value provider. Choose a non-hospital based center for a lower price.

3. You Travel Out-of-State to See Your Mom

If you leave your hometown and travel to another state, your network of hospitals and doctors may not necessarily come with you. Depending on the type of care you need, you may not be covered. It’s always important to check who is in your network – especially once you’re out of town.

Emergency Care is Covered Anywhere in the US If you’re having chest pains and think you may be having a heart attack, a local ER must see you and provide care. Emergency care is covered anywhere in the United States, whether or not you live in that state.

Call Before Receiving Other Types of Care What if you have a cold or the flu when you’re out of state? If you need to visit an urgent care clinic or local doctor, make sure you call your insurance first to see who is covered nearby. I know this won’t be the first thing on your mind, but believe me, it can save you a lot of money!

HOT Tip: We can’t stress it enough, if you’re ever out of town and need care, call your insurance company first. The only exception is emergency care. If you need emergency care, please go to the nearest ER immediately. Don’t waste any time calling – emergency care is covered.

4. You Break Your Leg While Climbing a Rock Wall in Cancun

What if you’re vacationing in another country and you get sick or have an injury like a broken leg? Unfortunately, you will not be covered once you leave the US. American health insurance plans will not cover you out of the country!

HOT Tip: If you travel out of the country frequently, you may want to look into Travel Insurance that includes health coverage.

Medicare Corner

If you’re over 65 and have Medicare Part A, the scenarios above are a little bit different for you. Medicare Part A doesn’t have a network. You can choose any provider in the country you want. When choosing a provider though, make sure you choose one who “accepts Medicare reimbursement” and not just “participates in Medicare,” because you could pay up to 15% more.

If you have a Medicare Advantage plan instead of Medicare Part A, you DO have a network, so make sure you contact your health plan in all of the situations above.

Have a Similar Story to Share?

We hope none of these things ever happen to you, but if they do, you’ll now know what to do. Have you or someone you know been through any of these things? Share your story in the comments below.

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