Did you know that you can save yourself a lot of time, frustration, and MONEY by being an
informed patient? You may be asking yourself “how?” The healthcare system, especially the
medical billing and health insurance aspects, are extremely complex and confusing. However, with
a little advance planning, you can reduce or eliminate endless phone calls to representatives that
are unwilling or unable to help you resolve the problem. Advance planning is also very likely to
help you save money on medical expenses. In this series of blog posts, we will give you the
necessary tools to help you make informed decisions and ultimately save you money.
What is a Health Insurance Network and Why Does it Matter?
Every hospital, free-standing facility, and physician has what is called a chargemaster rate. This
rate is typically an inflated amount related to the services that were performed during your visit.
These chargemaster rates are different among the various providers. The chargemaster rate for
an emergency room visit due to the flu might be $1,200 with Hospital A while Hospital B’s rate is
$1,800. Why is this important?
Literally, no one pays the full chargemaster rate. If you are uninsured or underinsured- you are
expected to pay this full rate. However, in most cases, a reduction can be obtained (be on the
lookout for a future blog post to explore this further).
Health Insurance Companies and Providers (hospitals, physicians, facilities, etc.) work together
to negotiate rates for every service, procedure, and supply called “allowed amounts.” This
agreement between a health insurance company and multiple contracted providers is what
creates the NETWORK. Doctors, hospitals, and other providers that do not have a contract with
the insurer are “out-of-network. IF YOU STAY IN-NETWORK amounts billed are radically less
than the chargemaster rate for covered services. Again—that is IF you stay in-network! When
you see a network provider, you are protected by the negotiated rates between the provider and
health insurance company. The provider cannot bill you more than the contracted allowed
amount for services covered by your health insurance plan. This does not apply to non-covered
or exclusionary services.
In some cases, such as having an HMO/EPO plan, out-of-network charges are not paid at all by
the insurance- leaving you with astronomically high medical bills. In other cases, your health
insurance company may make a small payment but, you are left with the remaining balance which can be substantial. Below you will find clear examples of the difference in costs from seeing an in-network vs. out-of-network provider for the same service.
Beth recently received a breast cancer diagnosis. Her primary care physician refers
her to a highly respected oncologist at a local cancer center. Without checking with her
insurance company, Beth schedules an appointment for an initial exam.
Here is an example of difference between the out-of-pocket cost had the oncologist been in-network vs out-of-network:
The Oncologist’s chargemaster rate for Beth’s initial exam: $550.00
The in-network health insurance allowed amount (based on the annual cost-sharing
The negotiated in-network discount amount: $350.00
The amount you may owe (based on your annual deductible, copay, and out of pocket
**The in-network provider cannot charge you more than the negotiated rate for covered
The out-of-network Oncologist’s chargemaster rate for the initial exam: $550.00
The out-of-network health insurance allowed amount: $100.00
The amount the out-of-network provider may try to collect from you (based on your annual
deductible, copay, and out of pocket maximum): $450.00-$550.00
**The provider is allowed to charge you more than the out-of-network “allowed amount”
as there is no contractual agreement with the health insurer (also known as balance
Beth’s savings by using an in-network provider were $200.00-$300.00
HOW TO AVOID GOING OUT OF NETWORK
Did you know that using an out-of-network provider is likely the greatest cause of exorbitantly
high medical bills? Providers and patients are not on the same page. Barely a third of doctors
discuss their charges with patients. Unfortunately, it’s the patient’s responsibility to know their
provider’s network status with their health insurance plan. One of the most commonly made
mistakes regarding confirming network status is relying on just the hospital or physician’s office
to provide you with accurate information.
There are many different networks offered by the same health insurer. If you call a provider and
ask, “do you accept Florida Blue?” The answer will almost always be “yes.”** (Florida Blue is the
largest health insurer in Florida)** However, Florida Blue has multiple plans with multiple
networks. Although the doctor or hospital you want to go to might be in-network with the Florida
Blue – Blue Options plan, they may not be in network with your Florida Blue – Blue Select Silver
Plan. A lot of times the physician does not even know which networks they participate in!
In order to verify your provider’s network status, you will need:
• The provider you wish to see’s name, service address, and contact number.
• The NPI (National Provider Identifier) – Contact your provider to request their billing NPI.
Ask if the provider bills the NPI as an individual or as a group. (Organizational healthcare
providers such as hospitals, physician groups, facilities, etc. would submit a claim under
a group NPI).
Once you have the information above, follow this triple-check system to help you avoid
going out-of-network unnecessarily. (Stay tuned for an upcoming blog post regarding
Surprise Medical Bills):
1. Check your health insurance web portal. Every web portal is different based on the
health insurance carrier. Typically, you can search by provider/facility name, specialty,
geographical location, NPI, hospital affiliation and more. If the provider does not
populate in the search results, they are most likely to not be within your plan’s network. If
you are unsure, refer to #2,below.
***NOTE: It is highly recommended that you register for access to your health insurance
web portal, if you haven’t already done so. Most health insurance web portals provide
access to your benefit details, claims submitted by your providers, amounts applied to
deductibles and out-of-pocket maximums, and other valuable resources. TIP-If you
are changing insurance companies, verify how long after separating from the company
you will have access to your information on the internet. Some companies only allow
thirty (30) days—other two (2) years.
2. Call your health insurance company directly at the number on the back of your card.
Give the customer service representative as much information regarding the prospective
provider as possible (name, address, specialty, NPI, etc.). Ask what the name of your
health insurance network is if you are unsure (see #3).
IMPORTANT: Always ask the customer service representative for a reference number at
the end of the call. Document the representative’s name, date, time,and details of the
call. This information can be extremely helpful if you experience any problems in the
future. For example, your claim could be processed out-of-network when you were
advised the provider was in-network.
3. Verify the network status information you received from your health insurance company
with the provider’s office. Ask for the insurance verification representative at the
provider’s office. Provide them with your Health Insurance Network information and the
details of your call with your health insurance company’s representative. Ask them to
confirm their network status.
4. A provider’s network status may change, sometimes without notice to you. Contracts
between insurers and providers are generally renewed annually (often near the beginning
of the calendar year). Check your established provider’s network status annually to avoid
If you receive conflicting information from either the health insurance company or the
provider’s office, ask to speak with a supervisor to help you clarify the discrepancy. Always
remember to document the name, date, details, and if available, a reference number for
every interaction you have with your health insurance company and providers.
It all boils down to taking a little extra time to verify and confirm your provider’s network
status with your health insurance plan. Ultimately, it is your responsibility to know your
provider’s network status, even in an emergency. Out-of-network, out of luck. Stay in-network, save a buck!
If you are unsure if your medical bills may have been processed out-of-network vs. in-network, or otherwise have trouble with medical billing and health insurance matters, contact one of our Board-Certified Patient Advocates at Human Health Advocates. We can help!