It is crucial to have medical insurance to avoid surprise bills that can drain you financially. Hence, many people are covered under health insurance plans. The Kaiser Family Foundation (KFF) states that around 170 million Americans are covered under some group or private healthcare plans.

When it comes to healthcare insurance, there are various options available to individuals. One such option is getting out-of-network care, which can be beneficial in certain circumstances. However, there are also potential drawbacks to opting for out-of-network care, and it is essential to consider all the factors before making a decision.

This article will explore the pros and cons of getting out-of-network care and help you decide whether it is the right choice.

What Is Out-of-Network Care in Insurance?

If you see a doctor that’s not part of your insurance network, it’s called out-of-network care. Out-of-network care can cost more than in-network care because your insurance company will not bear the complete cost of the treatment. If possible, the insurance company will only cover the cost of treatment not available with their in-house network doctors.

The out-of-network benefit is different depending on what type of health plan you have and which state you live in. Sometimes, it will cover 100% of the costs associated with an out-of-network provider. Other times it’ll only cover 25% or less.

People usually don’t opt for out-of-network care because of the associated costs. It’s not like there’s something wrong with out-of-network care. It’s simply that medical expenses have increased so much that taking out-of-network care can significantly impact a person’s financial condition. Data from the Centers for Medicare and Medicaid Services (CMS) states that healthcare expenses in the US reached $4.1 trillion in 2020.

In-Care Vs. Out-of-Network Care in Insurance

The main difference between in-network and out-of-network care is that the insurance company pays for 80% of the bill, while you pay 20%, or 60% of the bill, while you pay 40% when you opt for an in-network provider. This means that in-network care is cheaper because your insurance provider negotiates it.

However, they may not cover some or all of your expenses if you get treated at an out-of-network facility and don’t sign a form agreeing to let them treat you outside their network. If you want to save money on medical bills, it might be worth getting treatment at an in-network facility instead. However, there are a few scenarios where you might have to opt for out-of-network care, too.

How to Claim Out-of-Network Insurance Reimbursement?

Claiming out-of-network insurance reimbursement can be a complicated process. First, you must contact your insurance provider to confirm your coverage and the amount of reimbursement you are eligible for. Then, you will need to collect any necessary documentation from your providers, such as receipts or itemized bills.

After that, you must submit your claim to your insurance company, either online or through the mail. Finally, you will need to wait for your insurance reimbursement to be processed. It is essential to keep all your documentation and follow up with your insurance company if you do not receive your reimbursement promptly.

There are high chances that your claims will get denied. Many factors can influence the denial of the claim. For example, the insurance provider might feel it is a suspicious claim.

However, there can also be scenarios where there is no particular reason for denial. This is the case with both in-network and out-of-network providers. According to the KFF, around 1 in 5 in-network claims were denied by insurers in 2020.

When Should You Opt for Getting Out-of-Network Care?

As mentioned earlier, there might be various scenarios where you must take out-of-network care. Here are some such scenarios.

For Specialized Expertise

In-network care may not be the best choice if you’re looking for specialized expertise. Specialized experts are simply more skilled than generalists. Choosing out-of-network care can be a huge benefit if you have a rare condition or require specialized equipment and procedures to diagnose.

The problem with rare diseases is that little information is available about them. Hence, getting treatment from specialized physicians becomes vital. These specialized clinicians can also use their knowledge of your specific condition to help create an effective treatment plan.

However, the problem is that the costs can be high. According to a recent study, the medical and other costs associated with rare diseases can be substantial.

If you don’t have access to any specialized doctors in your area and need them, then definitely go with out-of-network specialists who can provide these services at an affordable cost. Otherwise, if there’s no urgent medical need driving your decision, it might make sense just wait until moving forward with treatment before deciding between in-network or out-of-network care options.

When Traveling

If you’re planning a trip, it’s important to know that you might be unable to find an in-network provider in your destination. For example, if you’re visiting a brand-new city or going to a rural area where there aren’t many doctors, finding someone who accepts your insurance plan could be difficult.

Out-of-network care may also be cheaper than in-network care. Specialists tend to charge more than primary care providers, which means that if you see an out-of-network specialist rather than an in-network one when traveling, the total cost of their services might still be lower than what they would have been otherwise.

Additionally, even though insurance companies usually cover some portion of out-of-network emergency room visits and hospital stays, they may not cover any costs related to nonemergency medical treatments.

So if these things need addressing while on vacation or a business trip and can’t wait until after you return home, the potential savings from using an out-of-network doctor may make up for any risk involved with going without coverage under most policies.

Medical travel insurance can cover a lot of expenses. Some of the costs it covers are ambulance service, doctor bills, room charges, drugs and medicines, x-rays, etc. Hence, taking travel medical insurance from your insurance provider is vital.

During an Emergency

If you’re in an emergency and need immediate treatment, you should opt for out-of-network care. The emergency room is not the time to worry about whether your insurer will cover the costs of a procedure or how much it might cost. You need to have access to the best possible care without hesitation.

The Affordable Care Act (ACA) recognized this reality. It included provisions allowing consumers to seek out-of-network emergency care without being penalized by their insurance company. These provisions remain intact under the current administration’s new ACA replacement plan.

For example, suppose you’re involved in an accident where life-threatening injuries are sustained after stabilizing your medical condition with an out-of-network doctor at a hospital. In that case, there should be no trouble getting reimbursed for all costs related to treating those injuries going forward, even if they weren’t considered “emergency” services by either provider or patient alike at first glance.


We hope that you understand out-of-network care better and when it’s the right choice. If you still have questions about whether or not it’s the best option for your situation, talk with an expert today.