Types of Out-of-Network Reimbursement
Summary
Most health plans have a “network,” a group of doctors, hospitals and other healthcare providers who agree to take your insurer’s rate. Some plans may not cover any services you get from providers who are not in the network. Others cover part of your care when you get services from other providers. But, plans may differ in how they decide how much they will pay out-of-network providers. Many of them develop their own “usual, customary and reasonable” (UCR) charges to help work out what they will pay out-of-network providers. Others use Medicare’s payment (fee) schedule.
- UCR charges. Most plans pay for out-of-network care based on a percentage of UCR charges. Those reflect what providers typically charge for a specific procedure in a given geographic area. Health plans make their own decisions about what is usual and customary. They may use resources such as FAIR Health, however, to help them make these decisions.
- Medicare fee schedules. Medicare’s payments are usually lower than payments from commercial health insurers. Some insurance plans use Medicare fees as a basis for reimbursing service for out-of-network providers. They then multiply that fee by a certain percentage to set the maximum amount that they will pay for that procedure.
The rate is often less than what your doctor charges. If you go out of network, your insurer may pay for part of the bill. You will pay the rest.
If your insurer uses the Medicare fee schedule to set its out-of-network reimbursement rates you can use the FH Medical Cost Lookup to estimate your out-of-pocket costs. Just select the “Medicare-Based” button on the right-hand side of your results page.
You may have the option to choose between plans—one that reimburses based on a percentage of UCR charges, and one that reimburses based on a percentage of Medicare fees. If so, you can compare your estimated out-of-pocket costs for services you receive out of network for both plans by using the FH Medical Cost Lookup. Select the “Compare Both” button on the right of the results page.
Your Action Plan: Understand Your Plan
There are times when you cannot avoid going outside your network for care. But, you should know what to expect and be prepared for the bills you receive. It’s very important to understand how your plan calculates its reimbursement rates before your visit.
Follow these tips to help manage your out-of-pocket costs:
- Ask your provider to refer you to in-network providers first unless there is a specific reason why you want to go out-of-network. If you are having a complex procedure, ask if all of your providers are in the network.
- If you choose to go out-of-network, ask the provider’s staff how much he or she will charge before your visit. Then, talk to your insurer to find out how much of the service your plan will cover.
- If your plan tells you they will pay a percentage of the charge based on Medicare’s fee schedule, ask how that will translate into a dollar amount.
- If your plan reimburses out-of-network care based on a percentage of Medicare, look up your out-of-pocket costs in advance by selecting the Medicare-based button on the results page of the FH Medical Cost Lookup.
- If you’re unclear about how your plan calculates out-of-network rates, or what services are covered, look on your insurer’s website, check your plan documents – or call your insurer and ask!
And most importantly – remember that you are your own best resource. Speaking up and asking your provider and insurer these questions up front will help you manage your out-of-pocket expenses.