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My Doctor is Out of Network-- Now what?

Updated: Feb 12, 2021

In the age of narrower doctor and hospital networks, my clients often face the issue of having a favored or required doctor not be in network for any available insurance plan. In some cases, a client may conclude that seeing that particular doctor is critical—even if the insurance company will not contribute to the costs.

If you are in a plan that limits benefits to providers in network, your visits to non-network doctors will not be covered, nor will your out of pocket costs be counted toward meeting your deductible or out of pocket maximum. In other words, you pay for these all on your own.

If you decide you must or want to continue using a doctor out of network for your health insurance plan, you need a strategy to manage your care across insurance coverage lines. Here are a few suggestions:

1. Embrace Teamwork

Try to create a feeling of teamwork between your in-network and out-of- network doctors. There are some differences in handling this task where your Primary Care Physician (PCP, family doctor) is out of network versus that when a specialist you want to keep is out of network.

a. If your PCP is out of network, you should find a PCP in your plan network and designate that doctor as such. This will give you the ability to get a free annual physical, including covered exams, get particular prescriptions filled, and access other things requiring a doctors’ time and orders. You will have to pay for visits to the out of network PCP you want to keep, but you can provide medical records created from covered benefits to that doctor to give him/her information needed to make good decisions about your care. If you become sufficiently confident in the new plan PCP, your former PCP could shift to role of reviewer and adviser.

b. If your specialist is out of network, you should be looking for providers with the same or supportive specialties in network. As with PCPs, you will be trying to get more routine or supplementary benefits paid by the plan or applied to your deductible.

2. Work out cash deals with the non-network provider. Rates can be lower for services paid directly to the provider in cash without the need to process insurance claims or account for discounts insurance companies receive from network doctors. Consumer Reports ( found this to be a viable option to check out—especially if your out of pocket costs within the plan would just be applied to a high deductible.

3. Consider options, like Employer coverage. Doctor networks are generally larger and more including for plans sponsored by employers. If your employer does not offer health insurance, you can ask them to consider it. If you have a business with only a couple of employees, you can sponsor a plan for that company. The options for small business insurance (under 100 employees), have grown and rates are competitive. Call me for a free no-obligation look at rates and options.

Working out side your insurance company doctor network is not fun or easy. If you decide you must do so, take advantage of methods to make this cost less and go more smoothly.

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