Top 5: Ways to Control the Cost of Healthcare #1

1. Utilize in-network/participating providers with your plan

Most insurance carriers create ‘in-network’ or ‘participating’ provider groups for their plans. These are providers that meet certain criteria and contract through the carrier to accept certain pay rates for their services. By going to an in-network or participating provider, you can help to control your healthcare costs and ensure that you are getting the highest possible benefit for your care.

For instance, if a provider is in-network for your plan and they bill $100 for an office visit but your insurance carrier has a contracted rate of $75, you will only be billed for $75, which will be applied to your deductible. However, if you were to go to a provider for the exact same service and they bill $100 but are out of network you will still owe $100 because they are not contract to accept the $75 rate. Additionally, only $75 will go towards your deductible. This is called balance billing, and if there is no agreement between the insurance carrier and the provider, the physician is allowed to bill you whatever amount they choose to charge.

Also, some plans are set up to have different deductibles for in and out of network claims. For instance, your benefits summary might look like this:

Covered Benefits	Network	Non-Network
Deductible Family coverage requires the family deductible to be met before coinsurance applies. The single deductible does not apply to family coverage. Network and Non-Network deductibles are combined.	$1000 individual $2000 family	$2000 individual $4000 family
Out of Pocket Maximum	$1000 individual $2000 family	$2000 individual $4000 family

Let’s say that these are your benefits and you go to an in network emergency room because you are having chest pains. After the visit, testing, and discharge, you are billed $3000. You provider adjusts this to their contracted rates for your services to $2000. Since you have individual coverage and no coinsurance after your deductible, you will owe $1000 to meet your deductible, $1000 will be paid by the insurance carrier, and $1000 will be a contracted write off for the emergency room. However, had that emergency room been an out of network facility and you were billed $3000, the insurance company would have applied the full $2000 of the contracted rate to your higher out of network deductible. Since this facility is not contractually obligated to accept their pay rate for the services, you will owe to full $3000.

In order to make sure that you are going to a participating provider, it is best to call the number on the back of your ID card or search your carrier’s directory for participating providers on your plan. If you are asking your provider, it is important to specifically ask whether or not they are contracted with your insurance carrier on your specific plan.

For more ways to control your healthcare costs, check out our Top 5: Ways to Control the Cost of Healthcare and check back often for articles explaining further each of these examples.