Different plans have different deductibles, copays, and coinsurances. Each plan is built around a unique set of providers that agree to provide medical care as part of the health plan. This includes physicians, hospitals, imaging centers, and other providers. If they agree to be in the plan, they are “in-network.” In-network physicians and hospitals are the providers the insurance company wants you to see. The insurance company has checked to make sure that each one provides quality care and they have all agreed to a contract where the insurance company will pay them to take care of you.s
Physicians and hospitals that are “out-of-network” are not in the health plan that your employer chose. Either the insurance company had an issue with the quality of the medical service or, more likely, they could not agree on the payment rates in a contract for paying the physician or hospital. If your beneft plan includes an out-of-network beneft, this means you’re allowed to see a provider that is not in the health plan your employer chose, but the insurance company and your employer may try to dissuade you from seeing them by establishing higher deductibles and coinsurances for out-of- network physicians and hospitals. If your health plan doesn’t include out- of-network benefts, then your insurance company won’t pay for you to see those providers at all. If you see an OON physician and you have no OON beneft, you should tell them to treat you as if you have no insurance. I’ll explain why later.
Why insurance may not pay and what to do about it
Every health insurance company has to have a physician to review claims. While people who work at these companies are very smart, they do not have licenses to make medical decisions, nor do they have the medical experience to understand specifc problems. I once had the privilege of meeting the medical director of a major health insurance company. He spent several hours talking to me and several of my colleagues about why insurance companies sometimes do not pay and what to do about it. He talked about the six most common reasons claims are denied. I have listed these reasons below.