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What if I want to see a provider that is not in my insurance plan’s network?

Can I negotiate a cash price?

There are some fairly common situations when you may decide that it’s in your best interests to see a primary care or specialty provider that is not in your network. Remember – you can always see anyone you’d like; not being in your plan’s network just means your insurance plan won’t pay for the visit. It doesn’t mean you can’t or shouldn’t see them.

An out of network provider may make a lot of sense for you if one or more of these are true.

You feel very strongly about working with this particular provider. You may have a very strong reference, or appreciate their unique skills, experience or reputation. Sometimes very good doctors either negotiate more aggressively with insurance companies, and end up left out of many plans, or walk away from insurance altogether and take cash only.

The provider may be more convenient or have open appointments that fit your schedule.

You can get a reasonable idea of how much your out of network provider is going to charge for the anticipated procedures. If, for example, the total charges are ‘reasonable and customary’ (ie not inflated ‘Provider Charge’ rates, but closer to your in-network Allowed Amount). This is often the case for providers who accept cash only, but is also possible for insurance oriented providers who just aren’t in your particular network.

If the total charges from the out of network provider are equal to or less than your forecasted OOP expenses with an in-network provider.   Or, if they’re more, and you consider the premium a good value based on your desire to work with that provider. This is more likely if you are currently on a high deductible health plan and don’t anticipate that this next visit will put you over your annual deductible; but be sure to calculate carefully. If you have a low deductible, or have met your deductible, your OOP expense for the in network provider may be very low since your insurance plan may be picking up the bulk of all of the in network Provider Charges.

If you do not anticipate exceeding your in-network deductible this year.  Even this visit won’t exceed your annual in network deductible; can you forecast the rest of the year?

 

Let’s look at some illustrations.

Let’s presume Bill has to go see a specialist. He knows for certain that he’ll need at least one visit before the end of the year, but he may need up to four. He also felt that, barring any unexpected accidents or illnesses, these specialty visits were the only scheduled care he’d receive through the rest of the year.

Bill’s primary care provider strongly recommends Dr. Sara Jones, but after checking his plan’s web site, Bill found that Sara is not in network. Bill was able to find a Dr. John Smith who is in network, but when he asked his PCP about John, the reaction was luke warm. Bill’s friend from work is seeing Dr. Mary Johnson and feels very strongly that she is the best in the business.  But Bill’s work friend also let him know that Dr. Mary didn’t take insurance – only cash.

Bill calls the customer service line at his insurance plan and asks what the Allowed Amount would be for the type of specialty visit he needs, and learns that it’s around $190 (click here if you’re not familiar with the difference between a Provider Charge, which is typically billed from a Provider, and an Allowed Amount, which has typically been determined or negotiated by an insurance plan).

He then calls Dr. Sara’s and Dr. Mary’s offices and asks the same question, acknowledging that he is effectively uninsured as far as they’re concerned, and learns that they’ll charge roughly $650 and $205 respectively. With that information, Bill sits down to look as his options.

 

If Bill has a high deductible plan (with a $6,000 annual deductible, of which he’s used $750), here’s what the numbers would look like …

 

Provider Charge for one Visit Allowed Amount for Bill’s Plan Bill’s OOP for one Visit

Bill’s OOP for four visits this year

Dr. John Smith   (In Network) $675 $190 $190 $760
Dr. Sara Jones (Out of network) $650 n/a $650 $2,600
Dr. Mary Johnson (Out of Network, posted cash price) $205 n/a $205 $820

Note:  The reason the numbers are so significantly different for the Provider Charges for Dr. Mary are because she does not accept insurance, and does only cash business.  That means she has to know what the reasonable and customary rates are for her services in her area, and publish and charge something close to those.  If she charged too much, she wouldn’t get any patients.  Too little and she’d be leaving money on the table.  She’s behaving like a normal participant in a transparent market, similar to dentists and most plastic surgeons.  She can’t play by the rules of the absurdly inflated Provider Charge/Charge Master game like doctors who primarily bill insurance.

 

Bill’s initial reaction is that – good news – the difference in his out of pocket expense between Dr. John and Dr. Mary is small enough that he’d enthusiastically go see Dr. Mary over Dr. John.   But then he remembered some advice he received from his brilliant friend about what do in these circumstances, so he picked up the phone and called Dr. Sara’s office back. This time he asked for Sara’s office manager, and explained that he wanted to see Dr. Sara and pay cash. Would they take $200 per visit?

He knew there were only a couple different answers he might get:

‘Sorry, if you don’t have insurance, we have to bill you $650’.

‘Sorry, no’. Followed by a click and the buzz of the dialtone.

‘Yes, we’ll bill you $200.’

‘Hmmm. How about $220?’

‘Well, we have to bill you $650. But if you call me back after you receive the bill and offer me $220 then, I’ll give you a receipt as Paid In Full and write off the difference’.

As it turned out, Bill got the fourth answer, which he was very happy with.

 

So now his options look like this …

Provider Charge for one Visit Allowed Amount for Bill’s Plan Bill’s OOP for one Visit

Bill’s OOP for four visits this year

Dr. John Smith   (In Network) $675 $190 $190 $760
Dr. Sara Jones (Out of network, negotiated cash price) $650 n/a $220 $880
Dr. Mary Johnson (Out of Network, posted cash price) $205 n/a $205 $820

With Dr. Sara at $220 instead of $650, he considered the cost differences between all three to be inconsequential. He then made his decision and scheduled his first appointment with Dr. Sara.

 

So you might ask – quite reasonably – ‘Why would Dr. Sara’s office manager agree to write off $430 from a $650 bill?’

The answer is simple, but illogical – she accepted, because neither Dr. Sara nor her office manager ever expected to collect $650 in the first place.  Dr. Sara treats patients from about 120 different insurance plans and bills them all $650 for the same type of visit Bill needs.  The Allowed Amount from Bill’s plan for his visit is $190, and the other plans (including Medicaid and Medicare) will pay anywhere between $122 to $238.  But NONE of them pay the $650 billed.  So Dr. Sara’s office manager made a very good business decision.  By virtue of Bill simply asking the question, she knew that Bill probably would not become a patient of Dr. Sara’s if he were going to be charged $650, since he probably already knew he had options at roughly one third that price.

So by negotiating a cash rate of $220, both patient and doctor win.

Dr. Sara gains a new patient at an acceptable rate.

And Bill gets to see his first choice doctor at an acceptable rate.

Is that The Cost Beast and the Quality of Life Serpent I hear crying in the distance?

 

If Bill has a low deductible plan ($1,000/yr, of which he’s used $750) with co-insurance of 20%, here’s what the numbers would look like …

The math for the available options now changes, since Bill meets his deductible with the second visit, but his co-pay then kicks in for the remaining visits for the year.

Provider Charge for one Visit Allowed Amount for Bill’s Plan Bill’s OOP for one Visit

Bill’s OOP for four visits this year

Dr. John Smith (In Network) $650 $190 $190 $352
Dr. Sara Jones (Out of Network) $650 n/a $650 $2,600
Dr. Mary Johnson (Out of Network, posted cash price) $205 n/a $205 $820

If this was Bill’s insurance situation, he would have to think harder about who to see. Even if he had the same negotiation with Dr. Sara’s office manager as described in the earlier example, the financial difference wasn’t consequential for the first visit, but once he met his deductible (his second visit would push him over the deductible threshold where all he had out of pocket was his 20% co-insurance), the financial difference did become a serious factor. This was a more difficult choice, but at least, Bill thought, he was making an informed decision.     He then made his decision and scheduled his first appointment.

It’s not always easy to get accurate information about the fees that are likely to result from a visit.   But the thing to remember is that with a few questions, you can often dramatically reduce the difference in cost between an in network and out of network provider.

 

Remember:  We coach, support, educate, and empower.  We illuminate options you may not have known you had.  But we don't decide what's right for you in your unique circumstances; only you can do that.  And we don't provide medical, financial, or legal advice; nor do we replace the valuable counsel of those who do.