If you’ve started looking for a health care provider for your child, you may have noticed that some providers are categorized as in-network and others are designated as out of network—but what does that information mean for you? 

We’re here to help you understand the ins and outs of in-network and out-of-network providers so you can make the best possible choices when choosing members of your child’s care team. It’s important to understand the differences in provider status with your health plan so you can make informed decisions when it comes to factors like reimbursement and logistics as you assemble your team. 

This guide can help you navigate the options and find the best balance of in-network and out-of-network providers for your child’s care plan. You’ll learn the difference between services being in and out-of-network, as well as some things to keep in mind when you’re deciding between providers.

What is an in-network provider?

In-network providers, also referred to as network-contracted providers, have a contractual agreement with health plans to accept a negotiated rate at which they will see patients covered on the plan. 

Any given health care or service provider may be network-contracted with several health plans or just one or two, so if your child is starting a new service or if you switch plans, it’s important to see if your chosen health care provider is in network with your particular health plan.

You can search on your health plan’s website for a list of contracted providers in your area who provide the service your child requires at the in-network level of benefits. Provider lists from a plan’s website may sometimes be confusing, so be sure to take the time to read through to make sure you understand the details.

For example, pediatric occupational therapy (OT), pediatric physical therapy (PT), and speech therapy may be separate lists, or an online search may generate a combined list for several provider types.

In addition, the same clinic may be listed multiple times because each treating therapist at the clinic will have their own individual network listing. The same clinic may also have multiple addresses listed, which can also add to the complexity of the list, so read through the list thoroughly before you start reaching out to providers.

You can also reverse your search and enter the name of a specific provider or clinic and see if they’re listed as network-contracted. Some clinics may have a mix of providers who are in network and others who are not, so you’ll want to contact the clinic directly to clarify if your preferred provider is in or out of network.

Once you have successfully navigated through the list of network-contracted providers, always be sure to check directly with the listed provider regarding their most current status with your health plan—contracts can change more frequently than health plan lists are updated.

Logistics are also a factor to consider when choosing a provider. In-network providers will handle billing and authorizations for your child’s services and will collect only a copay from you per session once the network deductible has been met. The providers know their contract rate, and they can help you plan in advance just how many sessions it’ll take to meet the deductible and what your share of the cost will be in dollar amounts once the deductible is met. They can also let you know about any session limits on the plan and take the lead to meet the need for any pre-authorization of sessions.

Once in-network services have begun, be sure to routinely check your health plan website and make sure that your child’s sessions are being billed and that the deductible and/or copay are being charged to you by the provider as the services are happening. The copay and deductible are your financial responsibility even if the provider falls behind in billing you for your share of the cost. Denied claims for services rendered are also your financial responsibility.

What is an out-of-network provider?

Out-of-network providers do not have agreements with health plans, so you’ll be responsible for the full billed amount that the provider charges at the time of service. 

The provider will issue you a superbill once your invoice is paid that you can then submit to your health plan for potential reimbursement. (A superbill is different from the invoice that you receive from a medical appointment or therapy session. It includes all the information your health plan requires to process an out-of-network claim for potential reimbursement.)

You’ll be responsible for knowing about and managing any needed authorization for services and informing the out-of-network provider of any reporting or other documentation required by your health plan.

In most cases, you’ll be submitting the out-of-network claim and you’ll remain out of pocket for the entire billed amount during the time it takes for the plan to receive, approve, and process your out-of-network claims for reimbursement; first to the out-of-network deductible, and then in payment to you.

Out-of-network deductibles typically also carry a higher dollar amount than in-network deductibles, and it’s important to note that reimbursement is rarely at the same dollar amount that you pay the provider. Instead, it’s based on an “allowed amount” or “maximum reimbursable amount” that’s often significantly below what the provider charges.

Once the first ongoing service claim is filed and processed by the plan, the out-of-network allowed amount will be known and you can calculate the difference between what the provider charges and what your plan recognizes for reimbursement. The difference in these figures may be quite substantial.

What to consider when you’re deciding between an in-network and an out-of-network provider

While network-contracted services may be logistically and financially more advantageous, there are other considerations to be aware of when choosing a provider based on network status. Other factors to keep in mind may include the length of the sessions, the provider’s level of training, the provider’s area of expertise, schedule availability, and wait time.

What is the duration of sessions (30 or 60 minutes) that the provider can offer for your plan’s contracted rate? 

Clinics or individual providers may sometimes offer a shorter therapy session to compensate for the reduction in the contracted amount that the health plans offer to the provider. The shorter session time allows providers to make the network services available at a rate that is both affordable to families and that makes sense for their practices.

What is the level of training of the treating therapist? 

A pediatric occupational therapist, a pediatric physical therapist, or a speech therapist will always conduct the initial evaluation session that your child receives. However, past the evaluation, services may be delivered by another individual who might be an assistant under the supervision of a licensed therapist. There are fine providers at all levels of training, but you’ll want to be aware of the credentials of the treating therapist your child is seeing. 

For example, a pediatric OT, a pediatric PT, or a speech therapist has a master’s or doctorate degree. A speech language pathology assistant (SLPA), a certified occupational therapy assistant (COTA), or a physical therapy assistant (PTA) does not. 

Your child may receive services from an assistant at an in-network setting as well. This is not a practice only at network clinics, so it’s a question you’ll want to ask when you’re searching for the best provider for your child’s needs, regardless of the provider’s network status.

What if there is a true lack of available network-contracted therapists who specialize in the specific areas of need that have been identified for your child?

Sometimes it’s necessary to work out of network to find a therapist that matches your child’s specific medically-prescribed care plan, such as an OT or speech therapist with feeding therapy certification, or a PT trained in orthopedic issues. 

In these cases, families may opt for the higher costs and increased logistical requirements of services with an out-of-network provider or consider filing a request for network-level reimbursement from their health plan.

What is the wait time for the initial session and the availability of suitable ongoing therapy times?

In-network providers (as well as out-of-network providers) will often have long waitlists for new families looking to join their practice for evaluation and treatment, so you should ask the provider what their waitlist looks like for the session days and times that work with your child’s schedule.

How Village can help

We know finding health care providers and therapists for your child may feel like a daunting task, and that’s why we’re here to help. When you partner with Village, we can help you find the care and support your child needs and streamline the process of managing your child’s care team. 

Book a free consultation to see how Village can make your provider search easier and help you easily coordinate care between your child’s providers.