What happens if you go out-of-network with insurance?

Going out of network with your health insurance usually means you will pay significantly higher costs, or your insurance may refuse to cover the service at all.

How Costs Change

• Higher Out-of-Pocket Costs: Out-of-network providers do not have a contract with your insurer, meaning they charge full, undiscounted rates. Your insurance plan will pay less or nothing toward the bill.
• No Coverage on Some Plans: If you have an HMO (Health Maintenance Organization) or EPO (Exclusive Provider Organization) plan, your insurance generally offers zero coverage for non-emergency out-of-network care, meaning you owe the entire bill. If you have a PPO (Preferred Provider Organization) plan, your insurance may cover a portion, but your coinsurance or copay percentage will be much higher.
• Balance Billing: Without a contracted rate, the provider can bill you for the difference between what they charge and what your insurance decides to pay. This is called balance billing.
• Separate Deductibles: Money spent out-of-network often does not count toward your in-network deductible or your yearly out-of-pocket maximum.

Important Exceptions

• Emergency Care: By federal law under the No Surprises Act, emergency services at an out-of-network facility or hospital must be covered at in-network cost-sharing rates.
• Specialist Exceptions: If your network lacks a specialist for your specific medical need, your doctor can request prior authorization from your insurer to treat the out-of-network care as in-network.

Whether health insurance pays for out-of-network care depends entirely on your specific plan type and whether the situation is an emergency.

When Insurance Will Not Pay

• HMO or EPO Plans: These plans generally offer zero coverage for non-emergency out-of-network care. If you see an out-of-network doctor voluntarily, you are responsible for the entire bill.
• No Out-of-Network Benefits: Some individual or narrow-network plans simply do not cover services outside their approved provider list.

When Insurance Will Pay (Partially)

• PPO Plans: These policies usually include out-of-network benefits. However, the insurance company will pay a smaller percentage of the cost (e.g., 60% instead of 80%), and you must pay a higher coinsurance or separate deductible.
• Allowed Amounts vs. Balance Billing: Insurers only pay based on a "reasonable allowable amount" for the area. Out-of-network providers can balance bill you for the remaining difference between their full charge and what your insurance reimburses.

Exceptions

• Emergencies: Under the federal No Surprises Act and standard insurance rules, true medical emergencies are covered at in-network rates even if you go to an out-of-network hospital or see out-of-network emergency physicians.

Yes, a doctor's office can "accept insurance" while still being out-of-network.

What "Accepts Insurance" Means

When a doctor's office says they "accept" or "take" your insurance, it often only means they will submit the paperwork (the claim) to your insurance company for you. It does not mean they have a contract with your insurance company to charge set, lower rates.

The Difference Between In-Network and Out-of-Network

• In-Network: The doctor signed a contract with your insurance company. They agreed to accept a set, discounted price for services. You usually only pay a small copay or coinsurance.
• Out-of-Network: The doctor has no contract with your insurance plan. They can charge full price for their services.

What Happens If You Go Out-of-Network

• Higher Costs: Your insurance might pay very little of the bill, or nothing at all (especially with an HMO plan).
• Balance Billing: The out-of-network doctor can send you a bill for the remaining balance between what they charge and what your insurance decides to pay. This is called balance billing or a surprise medical bill.
• No Cap: The yearly legal limit on out-of-pocket costs does not protect you from out-of-network bills.

Always call the phone number on the back of your insurance card or check the insurer's online directory to verify if a doctor is truly in-network before your appointment.

Doctors and their offices are generally not legally required to verify your specific insurance coverage or tell you if they are out-of-network.

Patient Responsibility

• Plan variations: Insurance companies have many different plans under a single name. A doctor's office might accept your insurance company overall, but still be out-of-network for your specific policy plan.
• Your duty: It is considered the patient's responsibility to verify network status before receiving care.

How to Check Network Status

• Call your insurer: Call the member services phone number printed on the back of your insurance card.
• Check online: Look up the provider using your insurance company's online directory.
• Ask the office: Call the doctor’s billing department (not just the front desk) and give them your exact plan details to ask if they are contracted with it.

Exceptions

• No Surprises Act: Federal law protects you from surprise balance billing for emergency services or unexpected out-of-network care while you are at an in-network facility, requiring providers to give notice and get consent in certain non-emergency situations.

When your doctor suddenly goes out of network due to a contract dispute or policy change, you may face higher out-of-pocket costs and balance billing.

Higher Costs and Balance Billing

• More expense: Out-of-network providers do not have negotiated rates with your insurer, meaning you might have to pay the whole bill or a much larger share.
• Balance billing: The doctor can bill you for the difference between what your insurance pays and their total charge.

Protections and Exceptions

• Emergencies: Under the No Surprises Act, true emergency room visits are still covered at in-network rates.
• Continuity of care: If you have a serious, complex, or terminal condition, or if you are pregnant, you may qualify for temporary in-network coverage for up to 90 days. You must apply for this through your insurance company.
• Dispute resolutions: Many contract rifts between insurers and medical groups get fixed after a few weeks or months. New agreements are often backdated, so keep your receipts if you pay out-of-pocket in the meantime.

What You Can Do

• Call your insurer: Ask the customer service number on your card about a continuity of care exception or a single-case agreement.
• Talk to the office: Ask the doctor's billing department for a cash discount or financial assistance.
• Opinions on negotiating: On Reddit, opinions are mixed on whether billing departments will lower unexpected out-of-network bills, but many users suggest asking for a reduced rate anyway.