Submitted by Misssheilala t3_10knwth in explainlikeimfive
Comments
IMovedYourCheese t1_j5rxgy0 wrote
In a world without insurance, you'd go to a doctor when you had a problem and they'd fix you and send you a bill, which you'd pay in full.
Insurance adds a layer to that, where you pay them a fixed amount every month and in turn they pay the doctor's bills.
Rather than paying 100% of everything, the insurance companies have certain rules – you have a deductible that you must meet yourself first, they will only cover certain procedures, they will only cover a max amount or percentage for each procedure and you must pay the rest yourself, and more.
Now, insurance companies also have tie-ups with certain doctors and hospitals. These doctors will have special rates just for your insurance provider, and so your insurance will cover more of the cost than normal. These are called in-network doctors.
This doesn't mean that out of network doctors won't be covered at all, but your insurance will just have stricter rules for them.
DragonFireCK t1_j5ry9fa wrote
"In network" means the doctor or location has a contract with insurance regarding payment rates and other details of coverage. Typically, this contract will also include provisions such as no "balance billing", where the doctor can charge you more than your insurance thinks is acceptable, requiring you to foot the bill.
A doctor or location "accepting" insurance means they are willing to bill the insurance directly. A location not accepting your insurance does not mean your insurance won't cover the work, but merely that you'll need to pay the doctor directly and file a claim with the insurance to be reimbursed.
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Presuming the US: There are also a few specific laws in place, such as insurance having to treat all emergency care as "in network" and balance billing being disallowed for such care. You also cannot be billed as "out of network" if you go to an "in network" facility and are treated, fully or partially, by an out of network provider, unless you are reasonably warned ahead of time that the provider is out of network.
Azeranth t1_j5ruj9k wrote
Your insurance has an advertised price for a procedure saying "we will pay upto X price". If the doctor thinks "well that's a fair price" then they accept the insurance. If not, they don't.
Sometimes they'll ask you to cover the difference between what insurance will pay and what the doctor charges.
These are different from co-pays, which the insurance expects you to pay before the insurance pays, meaning you pay no matter how much the insurance covers, even all of it.
Misssheilala OP t1_j5rvn8y wrote
Thanks for explaining. Do you know if they have to inform you of this? I ask because I’ve been with the same doctor’s office for 3 years and had multiple appointments with them through those years. But today when I went it I was informed I am out of network and they asked me to sign a form acknowledging so. This has never happened at any of my in person or telehealth appointments before today.
FSUnoles77 t1_j5rwfar wrote
Did the company you work for recently change insurance providers during their last open enrollment?
Misssheilala OP t1_j5s3a01 wrote
Nope! My insurance has been the same for the last 3 years and I selected to keep the same coverage during our open enrollment in November. To say I was caught off guard today would be an understatement.
Azeranth t1_j5rwbzy wrote
Generally the answer is sort of. They take your insurance information, and are not allowed to lie about being in network. That's insurance fraud and they get in big trouble.
They usually make you sign something agreeing to pay whatever insurance won't. This is sort of redundant, but you essentially are confirming that you understand that insurance may not fully cover your care. You should not have to sign this at an in network facility when undergoing non-elective care. Exceptions arise for emergency care where you sign on a blanket basis, because it's likely to overrun your premiums.
They are not legally required to tell you what the price will be and they are not legally required to honor the price advertised when they bill you. Importantly, they also can't just lie. They're bound by what's called "good faith". As long as they price they give you is honestly their best guess, they're off the hook.
Forcing medical providers, especially hospitals to publish and honor the price of their services not subject to insurance negotiation was a big part of Trumps healthcare reform initiatives, along with right to try and other misc small items.
Misssheilala OP t1_j5s3nbn wrote
They’ve never asked me to sign anything acknowledging they were out of network until today. I would have understood if my insurance changed (it hasn’t) or if they had dropped Aetna as a provider. When I asked them if they dropped Aetna they said they have never contracted with Aetna, which now I understand is different than excepting Aetna thanks to your first comment. All very informative and I appreciate your explanation!
rsclient t1_j5ryja2 wrote
Doctors decide (every year?) what insurance they will accept. I remember one particular year where essentially every single doctor in my area that used to take my insurance decided that the reimbursement rates (or the hassle factor) were too much and stopped taking the insurance.
My list of potential doctors went from "dozens" to "one" (and then that one doctor retired a few months later)
NorthImpossible8906 t1_j5rw6tx wrote
Both of those ("in network" and "out of network") can accept your insurance, and your insurance will pay a portion of the costs.
The main difference is that "in network" has agreed on what the cost of a procedure will be, and exactly how much insurance will pay for (taking into account deductibles and co-pays, and what insurance covers - for instance 80%). There is a fixed total cost.
Out of network means the doctor has not agreed to a price with you and your insurance company. The doctor can charge you much more. So you insurance will pay a certain amount but the doctor will bill you directly for the remaining costs.
For instance, you need surgery and it costs $5,000 according to your insurance company. An in-network place will charge you $5000 (and for instance, you might bay $1000 deductible plus 20% of remainder for a total of $1800).
However, go to an out-of-network place, and they might charge you $10,000. You insurance will kick the same $3200 dollars (maybe, they could just say it is flat out not covered), so you have to pay the remaining $6800.
Keep in mind you are always still paying your premiums for health insurance, but if you don't follow their rules and see their in network people, you typically get screwed. And this is a small example (like getting a wart removed). There can be medical bills in the 10s of thousands or hundreds of thousands dollars easily.
Note: this only occurs in the USA.
BadAtNameIdeas t1_j5rzzuu wrote
I had an ankle surgery in 2015, and it was supposed to be a 1 hour surgery tops. Well, there were complications, and my surgery ended up taking nearly 10 hours (one of the bones in my foot was so brittle that it literally shattered, which was just one of several problems my doc filled me in on). After a 3 night hospital stay, I go home. I paid a total of $2500 thanks to ridiculously amazing insurance (I worked at one of the big banks at the time). I later get the EOB (explanation of benefits) from my insurance company explaining how much they paid for the services, and it was almost $200K between my doctor, multiple visits from the anesthesiologist, hospital fees, 3 nights stay, and the best damn pain killers to exist on the market at the time.
snandrews7117 t1_j5rsw4s wrote
Insurance will have in network and out of network rates. In network gets special lower rates than out of network. So a doctors office can still accept it but not be in contact with that insurance.