Most health insurance plans contract with doctors, hospitals, and other providers to provide services at a discounted rate. These are known as in-network providers. Some patients must seek care from out-of-network doctors or facilities, but navigating the insurance process can be challenging. Here are some tips to help make it easier.

1. Get Reimbursed for your Out-of-network Services

When you choose a doctor or facility not part of your health plan’s network, you are likely to pay more for services than if you were going to an in-network provider. This is because the doctors and facilities in a health plan’s network have agreed to a discounted rate for services provided to patients covered by that health plan. 

However, some health plans—especially HMOs and EPOs—don’t pay for care if it is received from an out-of-network provider. And even for PPO and POS plans with cost-sharing limits, out-of-network costs can be a huge financial burden. Luckily, there are ways how to get insurance to cover out of network services. First, you should try to negotiate with your medical provider. 

You can also enlist the help of your in-network primary care physician. They can write your health insurance company a letter explaining why the request should be honored. Demonstrating how your out-of-network treatment will save the health insurance company money in the long run can make all the difference.

Additionally, you can use a tool to help with your billing needs. A payment processing system automates the process of submitting claims for out-of-network services to your health insurance company and fights to get you reimbursed. To use this, your patients link a bank account or card (credit, debit, FSA/HSA) to their account and then enter their health insurance information—a one-time process that takes less than 2 minutes.

2. Save Time Filing Claims

Whether you’re a patient navigating frustrating insurance claims or a provider filing out-of-network (OON) insurance claims, it takes time to get reimbursed for care. A payment processing system helps to make this process easier for everyone. The online payment system allows clients to link a bank account or card—like a credit, debit, FSA, or HSA—to their provider account. 

During the payment process, they can choose to have their outstanding insurance claim(s) filed automatically for free. They then send a SmartEOB—an easy-to-read explanation of benefits—to the client, including any reimbursement they owe for out-of-network services.

OON billing is a great way to provide a better patient experience and streamline your practice operations. It also saves clinicians the hassle of filing claims and helps ensure patients receive all their entitled benefits.

Before you can begin billing OON, it’s important to understand the payer’s claim submission requirements. 

3. Stay Compliant with your Insurance Plan

As a patient, you can do your part to avoid overpaying for healthcare by verifying that your providers are in the network. This can be done by calling your provider or using the insurance company’s online find a provider tool. 

Reviewing your plan’s coverage and benefits is also helpful so you are aware of any limitations that may affect the care you receive. The most important thing to remember is that you can only be reimbursed for out-of-network services if your health insurance plan allows for it. 

If you have a policy that doesn’t allow this, then it is important to talk with your provider about switching plans or getting a new one during open enrollment. For providers, a payment processing system is an easy and convenient way for patients to pay for their out-of-network services, and they will do all the insurance reimbursement work for them. 

There is no charge for patients who link a bank account; only 2.9% of a credit or debit card payment is charged to cover processing fees. As a provider, it is essential to maintain a professional demeanor when interacting with your insurance company and to be courteous. Keeping detailed notes on your phone calls and written letters is a good idea, and be sure to get the name of the person with whom you speak.

4. Stay on Top of Your Deductible

Each health plan has a deductible amount — the threshold that must be reached in payments before the insurance begins to pay 100% of costs. Depending on the project, some expenses don’t count against the deductible. For example, if John pays for an x-ray at the local clinic and the claim doesn’t go through the insurance, that $100 does not count toward his deductible. 

However, in a cost-sharing plan (like most HMOs), money paid for medically necessary services does count toward the deductible. Some people choose to schedule big procedures at the end of the year to meet their deductibles and have the peace of mind of knowing that the insurance will cover the remainder of their healthcare needs. 


A payment processing system allows patients to use a single, secure payment method for their out-of-network appointments. The patient receives a HIPAA-compliant email invitation to enter their credit card. They take care of the rest — filing the claims, fighting denials, and getting the reimbursements your patients deserve. This makes it even easier to ensure they are maximizing their insurance coverage.


Kenny is the founder and editor-in-chief of TheTalka. He launched the site in 2019.

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