When you need medical care, one of the most important decisions you can make is choosing a healthcare provider that accepts your insurance. Understanding the difference between in-network and out-of-network providers can help you avoid unexpected costs and make the most of your health benefits.

What is an in-network provider?

An in-network provider is a healthcare professional that has a contract with your health insurance company. These providers agree to offer services at negotiated rates, which are typically lower than standard. In-network providers may vary by doctor, hospital, clinic, laboratory, pharmacy and more.

For example, Sanford Health Plan has a contract with Sanford Health, so you can receive care from in-network providers at Sanford Health locations.

When you receive care in-network, you generally:

• Pay lower out-of-pocket costs
• Benefit from pre-negotiated rates 
• Have fewer billing surprises
• Receive the highest coverage available from your health plan

Consider this scenario: If you visit an in-network provider and your health plan covers 80% of the cost after your deductible is met, you may only be responsible for the remaining 20% coinsurance.

What is an out-of-network provider?

An out-of-network provider does not have a contract with your health insurance company. Because there is no negotiated rate, these providers charge their standard fees for services.

When you receive care from an out-of-network provider, you may:

• Pay more for the same services
• Have higher deductibles, copays or coinsurance 
• Be responsible for charges that exceed what your plan covers
• Need to submit claims yourself, depending on your plan

Some health plans offer limited or no coverage for out-of-network care except for emergencies, meaning you may pay more out of pocket.

Why does it matter where you receive care?

Choosing an in-network provider can significantly reduce your healthcare costs.

In-network care	Out-of-network care
Lower costs Predictable billing More coverage Easier claims processing	Higher out-of-pocket costs Potential balance billing Reduced coverage More administrative work

Even common services like specialist visits, lab tests or imaging procedures can cost considerably more when you use an out-of-network provider.

What is balance billing?

Balance billing is when an out-of-network provider charges you for the difference between the provider's full fee and the amount your health plan allows.

For example:

Provider charges	$500
Health plan allows	$300
Health plan pays	$240
Your responsibility under your plan	$60
Balance billing (your new responsibility)	$200

In-depth explanation:

• Provider charges: $500
• The provider billed $500 for your received care.
  
  
• Health plan allows: $300 
  • Your health plan determined they will only pay a maximum of $300 for the service. This amount includes both their payment and your portion.
    
    
• Health plan pays: $240
  • Your health plan pays $240 towards the allowed amount.
    
    
• Your responsibility under your plan: $60
  • You are responsible for $60 of the allowed amount. This may be because of coinsurance, a deductible or a copay.
    
    
• Balance billing = $200
  • If balance billing is allowed, you may have to pay the remaining $200 out of pocket because your plan does not cover the full amount.

Depending on applicable laws and your plan’s rules, an out-of-network provider may bill you for the remaining difference of your care. This additional charge can lead to unexpected medical bills.

Are emergency services covered?

Most health plans cover emergency services even if you receive care from an out-of-network emergency room or provider.

However, once your condition is stabilized, network rules may apply to follow-up care, specialists or hospital services. Always review your plan details to understand your coverage.

How can you find in-network providers?

Most health plans make it easy to find participating providers.

To search for providers:

• Use your health plan's online provider directory. Sanford Health plan members can access this provider directory. Log in with your member credentials to see whether a provider is in-network or out-of-network. 
• Log in to your member portal. Sanford Health Plan members can access their member portal here.
• Call the customer service number on your member ID card. Sanford Health Plan members can call (800) 752-5863 (TTY: 711) or email memberservices@sanfordhealth.org.
• Ask your provider's office to verify network participation.

Because provider networks can change, it's a good idea to confirm if a provider is still in-network before receiving care.

Tips for avoiding unexpected costs

Before scheduling care, consider these best practices:

1. Verify that your provider is in-network. 
2. Confirm that any specialists, labs, imaging centers or hospitals involved in your care are also in-network.
3. Understand your deductible, copays, and coinsurance. Sanford Health Plan members can log in to their member portal or call our customer service team at (800) 752-5863 (TTY: 711) or email memberservices@sanfordhealth.org. 
4. Review your health plan's coverage rules for referrals and prior authorization. Sanford Health Plan members can review this resource about prior authorization. 
5. Contact your health plan if you have questions about your coverage.

Frequently asked questions

Can I see an out-of-network provider if I want to?

In many plans, yes. However, your costs may be higher, and some plans may not provide coverage for non-emergency out-of-network care.

What if my preferred doctor is out-of-network?

You can contact your health plan to discuss your options. In some situations, special arrangements or exceptions may be available, depending on your plan and circumstances.

Do all health plans have provider networks?

Most health plans use provider networks, but network structures vary and each network has different rules regarding out-of-network coverage.

Different network types include health maintenance organizations (HMO), preferred provider organizations (PPO), exclusive provider organizations (EPO) and point of service (POS) plans.

Choosing the right provider for your needs

Knowing the difference between in-network and out-of-network providers can help you manage your costs and make informed healthcare decisions.

In general, choosing an in-network provider offers the greatest savings and the highest level of coverage. Before receiving care, take a few minutes to verify network participation so you can get the care you need while maximizing your plan benefits.