Can I See an Out of Network Provider? | Ep. 17

Your doctor recommends an out-of-network specialist, leaving you with a critical question: Can you see them, and more importantly, what will it cost you? This episode tackles the financial stress and confusion that comes with going out-of-network. Melody breaks down the problem into a simple, two-part framework to help you understand your options and your financial responsibility before you make an appointment.

Learn the exact steps to determine what your insurance will (or won't) cover, how to talk to the specialist's office about payment options, and how to avoid surprise bills. This practical guide empowers you to balance your health needs with your financial well-being.

Featured Topics:

• Understanding the difference between being able to see a specialist and affording one.
• How to check your insurance plan for out-of-network benefits.
• What does it mean if your plan has no out-of-network coverage?
• How to negotiate as a "self-pay" patient.
• The common ways costs increase for out-of-network care include higher copayments and coinsurance.

What You’ll Hear:

• [00:00] The Two-Part Question: Can I See Them vs. Should I See Them?
• [00:48] Step 1: Check Your Insurance Plan for Out-of-Network Coverage.
• [01:10] Scenario A: Your Plan Has NO Out-of-Network Coverage.
• [01:25] Proactive Tip: Talking to the Physician’s Office as a "Self-Pay" Patient.
• [01:54] Scenario B: Your Plan Has Out-of-Network Coverage.
• [02:30] Understanding Higher Financial Responsibility (Copays & Coinsurance).
• [03:15] Balancing Your Health with Your Financial Responsibilities.

Want to Ask Melody? Visit: https://takecarepod.com Don’t forget to subscribe so you won’t miss an episode. If your doctor has ever recommended an out-of-network specialist and you've worried about the cost, this episode is a must-listen.

Transcript

Speaker 2: 0:13

Hi everybody and welcome to this episode of Take Care. Question today comes from Sarah. My physician wants me to see a specialist, but that physician is out of network. Can I see this physician? And that's a great question. It really is a two part question I would say. So, can you see that physician? Yes. Should you see that physician or what is the financial impact, what are you going to owe? If you see that physician is really a little bit broader question. So, can you see a specialist out of network? The short answer is you can. When you call that physician's office, they may tell you that they don't take your particular insurance. But that doesn't prohibit you from choosing to go to that physician. It just means that you're going to have a different financial responsibility for that. So, that raises the next question, as we look at a physician being out of network, we go back to we want to make sure we understand our insurance benefits. So, we want to log onto that insurance company's website and we want to see with our plan, do we have coverage for out-of-network physicians? And some plans say, yes, you do. But you have to pay more out of pocket. Other plans say, Nope, we don't provide any coverage for out-of-network physicians. If you're in that bucket that no, they don't provide any coverage for out-of-network physicians, then you're going to be responsible for all the office visit for any procedures they might do. But this is where you want to have a conversation with that physician's office to say, okay, my plan doesn't cover out of network physicians, so I'm going to be considered self-pay. Are there any discounts that you can give me? Or what kind of payment am I going to be expected to have? So, you want to have those questions or conversation upfront so that you understand what potentially is going to be your responsibility from a financial standpoint. So,, you don't get any surprises on the back end. If you do have coverage with your insurance for out of network, what you'll look at is, well, what does that really mean? And for many insurance plans, it means that the copayment or the amount that you pay when you go visit a doctor is usually going to be higher for an out of specialty network, or out of network physician. So, for example, if you go visit a physician within your network and they're a specialist, you might have a$50 copay or a$75 copay. But if they're outta network, that number may go up. And so, it may be that you have to pay a hundred dollars out of pocket. Again, there's a lot of variation depending on what your insurance plan is, so I can't speak specifically to how much additional it would be. And then, the other component in addition to that office visit would be any procedures that either they do in the office or if you have a surgery scheduled, you're going to want to be aware of what your obligation is for that as well. So, if your plan allows out of network physicians, you would generally see a higher amount that you would be responsible for. So, as an example, if you're responsible for 10% of the allowable amount for an in-network physician, you might see that that amount goes up to 20% or 30% or even higher if it's an out of network physician. So, what you're going to see is a higher responsibility. So, can you go see that specialist? Yes. What is the financial impact of that going to be? That's going to vary based on your insurance plan. So, be aware of what your options are. And if that's something that is very stressful for you or not an option for you to see a specialist based on of what's going to be your financial responsibility, then can you see that physician? You can but maybe you shouldn't because you have to take into account balancing your financial responsibilities. So, that's it for this episode of Take Care. Please go on to the website if there's a question that you have. And leave it for me and I'll look forward to answering that in the future. Until then, take care.