When Should I Obtain Out-of-Network Health Care

Answer: There are several situations, many involving urgent care or provider shortages, when it may be best to use practitioners who are not in your health insurance network.

Whether you have an HMO (which limits care to your primary doctor and those he or she recommends), a preferred provider organization (which has a network of providers) or a point-of-service plan (combination of HMO and PPO), there's no question that out-of-network health care is generally more expensive. In a PPO or point-of-service plan, participating providers have agreed with insurance companies on predetermined rates for various procedures. These amounts are called "usual, customary and reasonable costs" (UCR), and they're usually lower than out-of-network providers will charge.

If your insurance pays 70% of the cost of out-of-network providers, it will only pay 70% of the UCR amount -- not 70% of the actual bill. This means you will have to pay the difference, which probably will be higher, possibly by thousands of dollars.

Reasons for Choosing Out-of-Network Health Care 

Sometimes you have no choice, or it just makes sense to choose a non-network healthcare provider. Under most of the following scenarios, you may be automatically eligible for or you can appeal for in-network coverage:

• Emergencies: In an urgent situation, you must seek the closest available help. Many plans make exceptions for out-of-network coverage during an emergency, according to the Health Rights Hotline. It's imperative that you or someone else contact your primary-care physician or your insurance company within 48 hours of your emergency treatment to improve your chances of getting coverage. If it's not truly an emergency, your visit will not be processed as in-network treatment; you should go to a covered provider instead.

• Specialized care: If you have a rare ailment for which no specialist is included in your plan, out-of-network care may be crucial.

• Changing providers would jeopardize your health: If you're in the middle of treatment for serious or end-of-life issues, and your provider leaves the network, it may be in your best interest to continue that care by going out of network. You can appeal for continued in-network coverage, if only for a period of time or a set number of visits.

• Out-of-town care: If you need medical care while away from home, you may have to go out of network, but some insurers will handle your visit to a non-participating provider as if it were in network. However, in-network providers may be available. If it's not an emergency, it's best to contact your insurer first to find out.

• Proximity issues: If you live in a rural area and there is no primary-care provider within a short drive or if you require a specialist and none is nearby, your continued health may depend upon using a non-participating doctor. In these cases, many companies will cover the cost at an in-network rate.

• Natural disasters: Floods, widespread fires, hurricanes and tornadoes can destroy medical facilities and force people to evacuate to other areas in which they must seek health care. Sometimes, these patients may be eligible for in-network rates as part of a declaration of emergency by the state or federal government.

You'll improve your chances of paying in-network rates for any out-of-network visits if you see your primary-care doctor first, according to the Virginia Bureau of Insurance. Ask him or her to officially recommend the out-of-network provider and write a letter to your insurance company about the necessity of that care. If you are part of an HMO, make sure you get a referral.

If you must pay out-of-network costs, ask the non-participating provider if he or she will consider discounting the services you need.

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