When Going Out of Network Coverage Makes Sense

If you have health insurance, there’s a good chance your healthcare is provided by an HMO (Health Maintenance Organization), a PPO (Preferred Provider Organization) or a point-of-service plan that combines features of HMOs and PPOs. In every instance, you get a preferential rate for using your plan’s network doctors, healthcare providers and hospitals. In the case of an HMO, you must stay in-network and use your primary care physician for referrals to specialists. The concept is that you save money on premiums by allowing your insurer to manage your care with limited access to a limited selection of healthcare providers. That’s the trade-off. Fair enough. But, what if you want to or have to go out of network coverage? When does it make sense? And when, if ever, can you get around the rules and in-network prices for out-of-network services?

Your Plan Pays, Maybe, Scenarios

There are several instances in most health insurance plans that allow you to go out of network and still have full or a percentage of coverage. Some require advance authorization and negotiation. Some you can appeal. And some are no-brainer automatic.

• Almost all plans allow you to use the closest available help in an emergency situation. If you’ve broken your leg or had a stroke, nobody expects you to waste time looking for an in-network hospital. The catch, however, is that you (or somebody you authorize) must contact either your primary care provider or your insurance company within 48 hours of receiving out-of-network emergency treatment. Fail to do that, and chances are you won’t be covered. Also, make sure it’s a real emergency by reading your policy and understanding the terms before a situation occurs.
• If you’re out of town on vacation or business and you become ill some plans will treat a visit to a non-participating provider as if it were in-network. But, unless it’s a true emergency, call you’re the 800# on your insurance card to get authorization or to find out if there is a network provider in the area.
• In the event of a natural disaster, where your network facility may be overwhelmed or destroyed, or if you’ve been forced to evacuate, you may be eligible for in-network rates from out-of-network providers. Your chances are best if an actual declaration of emergency has been issued by a government agency.
• Do you live in a more rural area? Many plans will cover out-of-network visits to a non-participating doctor if no in-network provider is within reasonable driving distance. Again, you should check first for authorization.
• If you have a condition that requires a specialist and none is participating in your plan, most plans will cover treatment at an in-network rate with prior authorization.
• If you are being treated for a serious or end-of-life condition and your provider leaves the network, you may be able to negotiate with your plan to allow you to continue seeing that doctor at in-network rates — although your insurer may limit the number of visits or the time frame.

Your Plan Pays Never, But Who Cares?

It’s still a free country and you can see any healthcare provider you want, as long as you’re willing to pay the price. There are a few instances when going out of network makes perfect sense:

• If you want a face-lift, a nose job or breast implants, go to the provider you have the most confidence in and pay for it out of pocket. Health insurance does not pay for elective cosmetic surgery.
• If you have a relationship with an out-of-network doctor — a gynecologist or dermatologist, for example — and want to stay with him or her for purely personal reasons, pay for the privilege.
• If you want a second opinion from an out-of-network specialist, expect to pay for it out of pocket.
• If you go out of network coverage and will be paying cash, be sure to let the provider know when you make your appointment. You may be pleasantly surprised to learn that services are discounted for cash payment.

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