Out-of-Network
Healthcare providers who have not contracted with a health insurer, typically resulting in higher costs for the patient.
What is Out-of-Network?
An out-of-network provider is a healthcare professional, hospital, or facility that does not have a contractual relationship with a patient's health insurance plan. Because no negotiated rate exists, the insurer may pay little or nothing for out-of-network services, leaving the patient responsible for a larger share of the cost. In PPO plans, out-of-network care is covered but at a higher coinsurance rate than in-network care and with a separate, higher out-of-pocket maximum. In HMO and most EPO plans, out-of-network care is not covered at all except in emergencies. Out-of-network providers may also engage in balance billing — charging the patient for the difference between their full fee and the insurer's payment — though the federal No Surprises Act limits this practice for emergency and certain non-emergency care at in-network facilities. Patients should always verify network status before receiving care.
Example
A patient undergoes emergency surgery at an in-network hospital but is treated by an out-of-network anesthesiologist. Before the No Surprises Act, the patient could receive a balance bill for thousands of dollars beyond their normal cost-sharing. Under the Act (effective January 2022), their out-of-pocket cost for this provider is limited to what they would owe for an in-network provider.
Source: CMS — No Surprises Act