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IN-NETWORK VS OUT-OF-NETWORK: WHAT TO KNOW ABOUT HEALTHCARE & INSURANCE

Contributed by Kyana Brathwaite, Founder of KB Cals


Oftentimes, we hear these two terms -- In-Network and Out-of-Network -- thrown around willie-nilly by those that work in the healthcare & insurance industries, but what do they mean? How do they affect the people using the system? These are questions I’ve had and am often asked. Let’s dive right in, shall we?

In-Network.

Defined by eHealthInsurance as "...health-care providers who are contracted by an insurance company, and provide medical care to those enrolled in plans offered by that insurance company."


Out-of-Network.

Defined by Very Well Health as "...one which has not contracted with your insurance company for reimbursement at a negotiated rate."


For those who are not familiar, hearing these definitions are A LOT to take in, especially if you've been struggling with crisis or mental illness and are ready to take the brave next step to seek professional help and therapy and also for those who are a healthcare provider and need to know which direction to take for your services. So, let's break it down.


What does all this mean for you as a provider?

For providers, you have options that you can offer to your potential clients, such as more affordable costs. Providers in a network give care to members in a health insurance plan and are included in a list, or provider network, qualifying you as meeting quality standards in providing healthcare resources. However, the process and financial gain can be more involved than receiving out-of-pocket costs for services.


What does all this mean for you as a patient?

Depending on your health plan, as the insured, you have options, too. If the provider (doctor, therapist, facility, etc) is in-network, your insurance has a contract with them. This means that you pay a copay, a specific amount of out-of-pocket expenses for health care services (in most cases, not all), to use their services and the insurance pays the remainder of what's due. If they are not in-network, the provider is considered out-of-network, then you, as the patient or client, are responsible for paying that provider for services completely out-of-pocket. Something to also be aware of is that your insurance company also offers reimbursement for out-of-network providers. This can get get tricky and you'll want to talk with a professional in healthcare or insurance or your provider.


Provider Network.

Usually, insurance companies provide a list (I call it a "laundry list" because it’s usually super long) of providers that they work with. This list can change, sometimes weekly or daily, it depends on how often your insurance provider updates their database.


Here's what I recommend...

  • Call the provider that you are interested in seeing.

  • Ask them for their NPI number (provider ID number).

  • While you have them on the phone, ask if they accept your insurance. If they say yes, call your insurance with the NPI number to double check that they are, in fact, in-network.

  • Then ask your insurance what coverages (aka how your plan works with seeing the provider) you have when being treated or seen by this type of provider.


If the provider is confirmed as in-network by both the provider and the insurance -- AWESOME! You have a winner!


If they aren’t in-network, you have a few options. With these options comes a bit of “foot work” but, ultimately, make sure that you are seeing a provider you want to see and aren’t paying more than you should or can.


It’s totally worth it to look into your managed-care plans and how they can assist you. I hope this helps to make the process less overwhelming, and I wish you all the best in your endeavours!



Kyana Brathwaite is a registered nurse, wife, mom of two wonderful kids, and CEO & Founder of KB CALS – Caring Advocacy & Liaison Services. Inside of her 18+ years in healthcare, much of her time was spent as a RN in the critical and acute care setting. By coordinating a community of support, including medical practitioners, health systems and insurance providers to best fit your needs, KB CALS partners with clients to assist in wayfinding, provider matching, benefit utilization, insurance research, and health and wellness planning. The process is interactive and participatory.


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