This phrase usually refers to physicians, hospitals or other healthcare providers who do not participate in an insurer’s provider network. This means that the provider has not signed a contract agreeing to accept the insurer’s negotiated prices.
Depending on an individual’s health insurance plan, expenses incurred for services provided by out-of-plan health professionals may not be covered, or may only be partially covered by an individual’s insurance company. Plans that cover out-of-network care are less common than they once were, but they are still available in many areas. They generally impose a higher deductible and out-of-pocket limit (or even no upper limit) when patients obtain care from an out-of-network provider.
And it’s important to understand that out-of-network providers can and do balance bill patients for the remainder of the charges after the insurance company has paid its share. In-network providers have agreed to accept the insurance company’s payment (plus the patient’s pre-determined cost-sharing amount) as payment in full, but out-of-network providers have not signed any sort of agreement with the insurer.