Have you heard the latin phrase quid pro quo before? In essence it means “I’ll do something for you if you do something for me.” This is the foundation of Managed Care in the US health system. Health insurance plans enter into contracts with medical providers where the providers agree to accept less payment than what was actually charged for the medical care if the health plan “steers” its members to the provider for service. It is basically discounts for patient volume. And we the healthcare consumers benefit from these agreements if we seek medical care from a provider who is contracted with our insurance plan: lower copays, lower deductibles, more covered services.
But sometimes we do go out of network for medical care. If the reason is due to a medical emergency, than we should still pay in-network rates. However, if we elect to go outside of the network, be prepared to pay more than just higher copays and deductibles. As explained in a recent Washington Post article, most states allow medical providers to balance bill you for whatever your insurance plan does not pay – this is on top of your copay and deductible amounts.