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The Importance of Controlling Your Costs by Staying IN NETWORK

Horizon Blue Cross Blue Shield of New Jersey developed the following information for their participants, but the concepts being conveyed apply to all networks and providers.

As a Health Benefit Plan member, you have access to a large network of qualified participating doctors, laboratories, hospitals and other health care professionals for your care.

Who is in our network?
Doctors, hospitals, laboratories and other health care providers and facilities are "in network" when they participate in a specific Network, ex Blue Cross Blue Shield of New Jersey or Magnacare in New York, where the charges for services have been pre-negotiated and agreed upon. You can easily find qualified doctors and other health care professionals, hospitals and other facilities that participate in the Provider Directories.
All doctors and other health care professionals who participate in these networks must pass a credentialing and review process. This process checks the credentials of doctors and other health care professionals including, but not limited to, licenses and certificates, malpractice insurance, educational background and hospital affiliations.  The fees are also reviewed and a set amount is agreed upon between the parties.

Who is out of network?
A doctor, other health care professional, hospital or other facility that does not participate with a particular health insurance plan is called an out-of-network provider.

How much will I pay for out-of-network care?
When you choose a nonparticipating or out-of-network provider for care, you pay more of the costs.
 An out-of-network doctor sets the rates you are charged and can bill you for any amount over and above what the plan allows for the 'reimbursement'* of the service. There are also different deductible amounts for out-of-network care.
Out-of-network providers are not required to accept your plan's reimbursement* as payment in full for their services. This means an out-of-network provider can bill you personally for the balance of the charges the plan has paid you for your claim.


For example, an out-of-network doctor may charge you $650 for a procedure, but your plan may only reimburse $194 for the procedure. The doctor can bill you the remaining $456. You may also need to pay a copayment or coinsurance and meet the deductible before the plan starts reimbursing you for any out of network claim.
This chart prepared by Horizon shows how much more a member might pay at an out-of-network facility, compared to an in-network facility:

These scenarios apply to doctors, laboratories and hospitals.  Staying in network will always be your most cost effective option.

Be Vigilant

Never assume that an in-network doctor is referring you to an in-network laboratory, hospital or consulting doctor.  Always check that the provider is IN NETWORK before receiving treatment.

Even if you are taken to the emergency room of an out-of-network hospital for urgent care, once you are stabilized and considered medically fit for transfer, you want to be moved to an in-network hospital for any additional care required. 

*reimbursement is calculated based on standard industry databases that supply fee schedules corresponding to the variety of service codes billed by medical service providers.

 

If you are with Magnacare your In Network Labratory is Quest Diagnostic

 

If you are with BCBS Horizon your in Network Labratory is Labcorp

Horizon