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How To Minimize Out Of Network Costs


To minimize out of network costs, consider the following steps:

Step 1. Call the doctor's office that you are considering using to provide the treatment or test

Ask for the person who handles billing for the correct name of the test , treatment or service and the  "CPT" code insurers use for it. The CPT code is a coding mechanism used by everyone in the health care system.

Step 2. If a test or a service that could be provided by your in network doctor is involved, ask your in network doctor to prescribe the test or service.

For example, if an out of network doctor wants a MRI or other test, ask an in network doctor to order the test for you. 

Step 3. If the test or service cannot be performed in network, call the insurance company and ask it to cover the out of network provider as an insider.

  • Describe the treatment or test and provide the CPT code.
  • Explain why you have to go out-of-network. For example: there are no specialists in your particular situation in your area or none of them have the experience with your situation that makes it most likely that you will get the care that will provide the best results.

Step 4. If the insurance company will not treat the out of network provider as an insider:

  • Get prior approval to go out-of-network if that is required under your policy.
  • Ask for the dollar amount the company pays for the particular test, procedure, consultation or health care facility care according to the CPT code. If the representative doesn't want to disclose the amount, ask for his or her supervisor. If the supervisor continues to refuse, remind him or her that the Department of Labor issued an advisory that says the charges the insurer uses for reimbursement should be disclosed to patients. While the opinion only covers policies subject to the federal law known as ERISA, it is difficult for a company to argue that information should be given to people protected to ERISA, but not to you. (To see U.S. Department of Labor opinion 96-14A for yourself, go to: offsite link). To learn more, see: ERISA

Step 5. Ask the out-of-network provider if he or she will accept the insurance company's out of network payment.

Step 6. If the out-of-network provider will not accept the out of network payment, what will the charge be?

  • Remind  the person that you are insured. Doctors and other health care providers have different charges for the same service depending on who pays. Uninsured people usually pay much more for the same service than people who are insured.
  • Confirm that the charge is for the correct CPT code.
  • Once you have the dollar amount, ask what the charge would be if Medicare were paying. Medicare usually pays a lower rate.

Step 7. Negotiate the price, or ask a family member or friend, or a professional to do it for you.

For an estimate of reasonable charges in your area for out of network services, click here. When you see charges, you are likely to also see that they are listed in percentiles. For example,  you may see something like the following:  

CPT         Code Description             50th         60th       70th       80th     90th

45378         Colonoscopy                 $764        $783      $859     $907   $1008

This means that, for instance, 60% of the doctors in your area charge $783 for the procedure. $859 includes 70% of the doctors' charges in your area. Plan designers and administrators of particular health care benefit plans may choose different percentiles for use with applicable health care benefit plans. To find out what percentile your company uses with respect to your particular plan, contact your insurer's customer service line.

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