GBS Advocacy
Insurance Insights
In-Network vs. Out-of-Network
Why Choose an In-Network Doctor / Facility?
In-Network providers (doctors, hospitals, etc.) have signed a contract with your insurance company to provide services at pre-negotiated rates. Typically, this means you will pay lower out-of-pocket costs because the rates have been discounted.
Important Terminology To Understand
Medical Billing / Claims
Full Fee: This is the total cost of a service at your doctors’ office regardless of insurance.
In-Network: A doctor/provider that is In-Network has signed a contract with your insurance company to provide you services at a negotiated rate that is usually discounted from the provider’s full fee.
Allowed Amount: The allowed amount is the maximum your insurance plan will pay for a covered service. Can also be called “negotiated rate” or “payment allowance”. This amount can vary depending on if the provider is in or out of network.
Out-of-Network: If you receive services from a provider/facility that is Out-of-Network there is no negotiated discounted fee, and you will be responsible for paying your providers full and total cost.
Balance Billing: When you receive services out-of-network you will be responsible for the difference in cost between the providers full fee and your insurance companies allowed amount. If your insurance plan pays 50% they will pay 50% of the allowed amount NOT the providers full fee.
Write Off: If you receive services from an in-network provider they will “write off” the difference between their full fee and the allowed amount. This amount is not your responsibility when in-network.
Amount Paid: Is your insurance plans payment to the provider. This is based off your benefit percentage and the insurance companies allowed amount.
Patient Responsibility: The amount YOU owe after a claim is paid by your insurance and all applicable write off’s have been applied.
In-Network vs. Out-of-Network
The patient that had their services completed in-network spent $100 less than the patient that received services out-of-network.
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