Out-of-network (OON)refers to patients receiving care from physicians, hospitals or other healthcare providers that are not inside a patient’s provider network. Now, most insurance plans restrict patients as to what medical providers they can see, by refusing to pay for those services and care. However, this phenomenon won’t go anywhere for the foreseeable future. Here are the three main reasons why:


1. Increase in Narrow Networks

health insurance claim form and bill receipt

Inside the US healthcare market there is a common phenomenon, known as narrow networks. This refers to healthcare plans that limit the patient to receive care from a handful of health care providers and hospitals covered in-network for a cheap premium. If the patient visits medical providers that are out of their network they will have to pay more money. Narrow networks are a popular plan offering in healthcare. It’s available to 92% of the population and it accounts for 73% of all Affordable Care Act (ACA) or “Obamacare” plans offered in the marketplace.

Although ACA did not create the concept of narrow networks, it definitely spurred it significantly since it was established in 2010, because it offers cheaper premiums to customers. But since narrow networks feature a limited amount of medical providers, they are leading to more OON care and therefore, patients receive surprise medical bills that they can not pay, a study by Physicians for Fair Coverage revealed.


2. Is a Big and Profitable Market

asian woman doctor holding a tablet

Annually, around 18 billion out-of-network health claims are made annually. Every patient is susceptible to receiving them because both out-of-network and in-network patients are receiving OON claims for procedures. As a result, the OON market makes $60 billions a year for claims.

For providers, being OON of payers allows them to receive more reimbursement for their services and raise their profit margins. Many medical providers are becoming aware of this and, therefore, have opted to have independent practices.


3. Patients Are Choosing the Care They Want

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The most attractive reason for patients to opt for out-of-network is the fact they can choose any provider they wish. Patients have the freedom to decide which doctor, hospital, health facility or lab to choose.  As a result, there has been a rise in tools that aid patients in the reimbursement process of OON claims. Such is the case of Claimeye. Therefore, patients don’t have to worry anymore about going out of their network, or even handling the process of submitting their out-of-network medical claims.


Try Claimeye to submit your medical claims faster.

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