Knowing Your Insurance Network
By Jordan Epstein
If you don’t have insurance, then you can go to any provider and pay the cash rate (but be sure you ask for their discount cash rate first—I’ll have another article out on this topic soon). But if you’re insured, you’ll need to find out whether a provider you’re considering is in-network or out-of-network., whether your plan is multi-tiered, and if you’re based on the exchange, whether your center is freestanding or outpatient.
In-Network vs. Out-of-Network Care
Your insurance will pay a larger percentage of in-network care than it will for out-of-network care, and sometimes out-of-network care won’t be covered at all. So if you can, you should choose an in-network provider. Be sure that both the facility (which could be a hospital or an independent center) as well as the radiologist (one of the facility’s doctors who is an expert in medical imaging) are in-network for your insurance plan. You can call the provider to check that both the facility and the radiologist are in-network. Be sure to use the word “in-network” and not “covered,” because some facilities can be deliberately misleading and say that you are “covered” when they are out-of-network, because your plan includes both in-network and out-of-network benefit. If a facility can’t or won’t answer the question of whether they and their radiologists are in-network for you, go somewhere else.
Some of you, especially those insured directly by hospitals or academic medical centers, might have a multi-tiered plan. Multi-tiered plans usually have ‘Gold’ or ‘Preferred’ in-network providers, which often have little to no cost-sharing for you as a patient. It’s important to know and seek out those top-tier providers–call your insurance company or your company’s health administrator.
Freestanding vs. Outpatient Centers
If you’re based on the exchange, you might see a benefit that distinguishes between ‘freestanding’ and ‘outpatient hospital’ centers. Unfortunately, neither your insurance, that center, or anyone else actually knows what type of center your insurance will definitively assign to which category, but you can take a guess and google the imaging center. If it seems to be affiliated with a hospital or medical group that sounds familiar and does more than just imaging, it’s probably not freestanding.
Deductibles can vary from nothing to several thousand dollars, and often for high-deductible plans, you personally—not your insurance company—will be responsible for paying the full price. You can confirm your current deductible status by calling your insurance company or logging onto their website. Check on your imaging benefits by looking for a document called “Summary of Benefits” and searching for the right benefit for your procedure, usually ‘MRI/CT’, ‘Mammogram’, ‘General Diagnostic’, or ‘Xray’.