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What should I do if I end up with an out of network provider; either by choice or accidentally?

If you deliberately choose an out of network physician – which does make sense in some cases – don’t miss the opportunity to negotiate a reasonable cash price up front for their services.  This is the best situation for you since you’re dealing with it up front and you always have the leverage to go somewhere else for care.

You’re in a more difficult situation if your in-network doctor or hospital gets a consult from an out of network provider, or sends diagnostic tests to an out of network diagnostic service provider without you knowing about it.  Now you’re dealing with it after the fact, and you may have signed an Informed Consent document that financially obligates you to pay up.

If that’s the case, here are some things to look for as you review your Explanation of Benefits;

Are the prices they’re charging me reasonable? Be very careful with this one, because the default for billing a patient outside of an established payer/in network provider relationship is to bill the full Provider Charge from the Charge Master, and these are almost never reasonable and customary rates.  Try a couple of Pricing Tools to get a sense of reasonable and customary rates in your area, but also be aware of all the different ways The Cost Beast can sneak up and bite you.  You are now in a negotiation, but that’s OK since that’s actually what this provider expected in the first place.

You have several options to consider;

The path of least resistance is to call their customer service rep, explain that you understand how Charge Master billing works, and offer to pay them a low figure you consider reasonable – say 20% of what they billed. If they take it, terrific. More likely they’ll try to negotiate it up. If you reach a comfortable number, settle and pay it.

Another option is to get more concrete information by requesting the CPT codes for the services you received, and put them into the AMA CPT Code Lookup Table. There you will select your state, add the CPT code, Submit, and see the ‘Facility’ (which means hospital owned) and ‘Non-Facility’ (which means non-hospital outpatient clinic) Medicare fee schedule rates for that procedure. Medicare is pretty aggressive at setting favorable fee schedule rates since they have so many patients, so subjectively, a reasonable and customary fee would be somewhere between 110-130% of the Medicare Fee. If the price looks acceptable to you, then pay it. If it’s 200+% the Medicare fee schedule (twice as much or more), then consider making a counter offer of something closer to 130% and see if they’ll take it.

If the bill is large, you can also hire an advocate to help you. These are generally career level professional billers who have been working for either doctor’s offices or hospitals. They understand the intricacies of the process, and know how to push the right levers with the provider representatives to work out a reasonable settlement.

Should you submit your out of network bill to your insurance company regardless? The value in doing so is to insure that it counts against your out of network maximum deductible. Since these are normally quite high, many people will simply hold on to their out of network bills that they’ve already paid, and if they feel they’re getting close to their maximum out of network deductible later in the year, submit them all then.


Next:  Sometimes excluded benefits are of high value.  Here are some pointers on how to prepare and avoid overpaying if you choose to consume an excluded benefit.


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.