Why Insurance Companies Consider some Healthcare Providers to Be “in Network” and Others Not


Why Insurance Companies Consider some Healthcare Providers to Be "in Network" and Others NotBeing in – network is a good way to grow business for the providers as well as insurance companies. Moreover, even the patients can get benefited with such an association. When a patient is choosing a physician it would do him good to select a provider who is in – network with an insurance company & who can provide good insurance coverage. This is like killing two birds with one stone. One goes in to get treatment and comes out with a killer insurance coverage plan.

The reason insurance companies consider some healthcare providers to be in – network and other’s not because at some stage physicians and insurance companies might decide to join hands where they agree to refer each other when they see a new person. So if a physician gets a new patient they will refer them to get insurance coverage from insurance companies with whom they have an association. Similarly, when a new person comes in to get insurance coverage they will be advised to meet a particular physician with whom the insurance company has an understanding. To make this more enticing they can offer certain benefits if they visit the in – network physicians.

Balance Billing

It is actually quite difficult to determine the kind of cost that will be incurred when one goes for treatment. Even physicians try and avoid giving an estimated cost. However, in case of treatments like childbirth a rough estimate is given. Hence, when someone goes in for a planned treatment it would do them well to check if the hospital or doctors that they visit are in the insurer’s network or not. If one opts for an out of network care; one might end up paying more, in some cases one might not be able to use out of network medical doctors.

One gets hit by unexpected medical bills if they unwittingly get care from a facility or doctor who does not participate with the insurer. In such a case the physician gives balance bills which is the difference between the insurer’s payment and the total charge.

Although the balance bill situation does not end only with an out network physician. The hospital and doctor can be a part of the network but the anesthesiologist might not be and he may be pricey too so there is again a balance bill.

Advantages of an In – Network physician

The advantages of going to an in – network physician are:

  • One pays considerably less when they go to an in – network physician
  • Easy access to different physicians for different ailments
  • Proper guidance as to which physician one should go to
  • The insurance company would make sure that they tie up with good qualified doctors hence, patients get quality treatment

Finally, one should understand that if a good physician ties up with a new insurance company or vice versa it is always helpful for the new physician or insurance company as they get back up from an established doctor or insurance company.

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