The Complete Guide to Out-of-Network Reimbursement

Everything you need to know about out-of-network reimbursement in under 7 min

Scratching your head over out-of-network reimbursement? Don’t worry, SuperBill’s got you covered. In this guide, we’re answering questions about all things out-of-network, meaning your OON doubts are about to dissolve. 

Wondering how to get out-of-network claims paid? Trying to find an out-of-network specialist your healthcare plan will cover? Want to know more about the difference between in-network and out-of-network? Whatever your question may be, we’ll do our best to answer it.

In-Network vs Out-of-Network Coverage

When you visit a doctor or healthcare provider from your insurance plan’s approved list, you’re seeing an in-network provider. Out-of-network (OON) providers are any providers outside your plan’s approved list. 

Some health insurance plans only cover in-network services, while other plans cover both in-network and out-of-network services. Even if your plan covers out-of-network services, it most likely covers a higher percentage of the cost for in-network services. 

However, there’s a common misconception that out-of-network services are not covered by insurance at all. In reality, many health insurance plans will pay for somewhere around 50-80% of the cost of out-of-network services, assuming you’ve met your deductible.

If your insurance plan does not offer a wide range of providers or services within its network, it may make sense for you to explore your out-of-network options. This is often the case for therapy or other forms of specialized care.   

What is a Deductible?

A deductible is the total cost of medical services you must pay yourself before your insurer chips in. For example, if your deductible is $2500, you must pay for $2500 worth of services before your insurer pays for the services they’ve agreed to cover. 

Usually, plans with lower premiums (the amount you pay each month for your insurance) have higher deductibles, and vice versa. 

Take note that many plans have separate deductibles for in-network vs out-of-network services. OON deductibles tend to be higher than in-network deductibles.

After you’ve met your deductible, you generally just pay a copay or coinsurance for covered services. At the end of your plan year, the deductible resets to zero. 

What Do Deductibles Mean for Out-of-Network Insurance?

In most cases, meeting your deductible will bring the cost of OON services down significantly. This is because most healthcare plans only agree to cover the cost of OON services after your deductible has been paid. 

For routine services like therapy, it might not take very long to meet your deductible. After that, you’ll only have to pay a percentage of the cost for OON services, the coinsurance, assuming your plan includes it. 

Coinsurance vs Copay

The coinsurance is the percentage of additional medical costs you agree to pay after you’ve paid your deductible. For instance, if your plan has a 20% coinsurance, once you meet your deductible you’ll only owe 20% of the cost of any other covered services you receive. The insurer pays the rest. 

In this example, if you get an MRI that costs $1,000 and you’ve already met your deductible, you’ll owe $200, and the insurer will pay the remaining $800. 

A copay (short for “copayment”) is a fixed dollar amount you pay up front for medical services. It’s usually applied to more common services like doctor’s visits or prescription drugs. 

Copays can vary by treatment but tend to be under $100. Coinsurance generally applies to more costly services. 

It’s important to recognize that plans with lower coinsurance rates—although they make you pay less for services—often have higher premiums. 

Cost Differences Between Copays and Coinsurance

Let’s take a look at how copays and coinsurance might affect your out-of-pocket costs.

Copays: If your copay to pick up a routine prescription pill is $15, you’ll pay $15 every time you pick it up from the pharmacy. No surprises there. However, your copays for less routine services like lab tests or physical therapy could vary.

Coinsurance: With coinsurance, the amount you’ll pay increases relative to the cost of your care. So, if you visit a therapist who charges $200 per session, and your coinsurance is 20%, you would pay $40 and your insurer would pay the other $160.

With both copays and coinsurance, the costs generally increase for out-of-network services, though not as much as you might think. It’s pretty common for insurance plans to bump a 20% in-network coinsurance rate up to 30% for OON services, for example. 

Do Copays and Coinsurance Count Toward Deductibles?

Copays do not count toward deductibles in most plans. And since coinsurance can only take effect after a deductible has been met, your coinsurance will never count towards your deductible. 

How Do I Know What Procedures Are Covered? 

You can always find a list of approved services and providers on your health insurer’s website. The website should also show a comparison of coinsurance rates and copayments for in-network vs out-of-network providers. Make sure you’re looking at your specific plan, because health insurance can vary from patient to patient. 

You can also find a lot of this information in your Explanation of Benefits, or EOB. An EOB is a document your insurer sends you to indicate what services they’ve paid and why. For a more in-depth explanation of EOBs, read What's an Explanation of Benefits and How Do I Read It?

Alternatively, you can use SuperBill to check your benefits for you. In addition to verifying benefits, we file claims, amend the rejected ones, and file them again to get you the maximum reimbursement you’re allowed. All you have to do is sign up and upload your medical bills.

It’s especially important to double-check your covered services before visiting an OON specialist. Many specialists, like therapists, dietitians, chiropractors, psychologists, psychiatrists, clinical social workers, and more choose to work outside of all healthcare networks, but your insurer may still cover a portion of the cost through coinsurance.

How Do I Get My Insurance to Pay for Out-of-Network Services?

If you’re stressing over how to get out-of-network claims paid, take a deep breath—there are more options available to you than you might think. In some cases, going out-of-network can be a more effective way to seek care than staying in-network. Read The Case for Out-of-Network Reimbursement for more on that.

You can ask your insurer for an out-of-network exception. If you know in advance that you’ll need to see an OON specialist, you may be able to get your insurer to agree to a network exception. A network exception means that your insurer applies your in-network benefits to out-of-network services. Pretty handy.

A couple common cases in which insurers agree to network exceptions are when there are no in-network providers in your immediate area, or when a certain OON provider has a level of expertise that in-network providers don’t. This is when studying the finer details of your network providers pays off; it may be tedious, but it can save you a lot of money. 

You can also negotiate with out-of-network providers directly.  Many providers will offer you a discounted rate in exchange for paying in cash or agreeing to a shorter time frame for payments. 

Consider too that SuperBill’s concierge support comes with this exact kind of assistance. We’ll comb through your health insurance plan to make sure we’re getting you the best prices you can get. 

Does PPO Cover Out-of-Network Services?

Yes! In general, PPO (preferred provider organization) insurance plans do cover OON services, although at a somewhat higher cost than in-network. In contrast, HMO (health maintenance organization) and EPO (exclusive provider organization) plans usually only cover in-network services. 

Knowing the type of plan you’re on can make a big difference!

But Wait, What are Allowed Amounts?

There’s still one more stop on the road to reimbursement. An allowed amount is the maximum cost your insurer agrees to cover for certain OON services. You can find your allowed amount on your insurer’s website along with the rest of your plan details. (By the way, we cover this in depth in our post, What is an Allowed Amount?) To illustrate how allowed amounts work, let’s do a little math. 

Imagine you see a therapist who charges $200 per session. You’ve already met your deductible, so your insurer has to pay their portion of the cost. Your coinsurance is 25%, so the insurer is responsible for the other 75%, but suppose your allowed amount is $180. 

This means the insurer only really agrees to pay 75% of $180, which comes out to $135. You have to pay the extra $20 on top of the $45 you owe for coinsurance. 

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