Provider Network

What Is a Provider Network?

A provider network is a group of individual healthcare providers that combine their services in order to help lower costs for patients. This usually occurs through an HMO or a PPO. Each provider network covers different medical procedures, and they usually offer more coverage than typical health insurance providers because of the variety of doctors who are working under the umbrella of that network. 

The following are two terms everyone needs to know about provider networks: 


If a health provider is in-network, the medical services you receive will either be covered by your health insurance provider, or total cost will be reduced. 


If your health provider is out-of-network, the medical services your receive will often not be covered by your health insurance provider, or more expensive than if you were to stay in-network.

How the Provider Network Works

A provider network helps keep costs down for individuals and also gives them access to a wider variety of healthcare options under one insurance umbrella. 

The first thing to do before seeking services from any provider is to determine whether or not they are in-network. If they are, you can obtain their services. If they are not, there are some other steps you can take to get coverage from that doctor, or you can look somewhere else for medical treatment. 

Just like typical healthcare coverage, you will have to pay a deductible for most doctor visits even if they are in-network. One of the reasons for this cost-sharing procedure is to ensure that patients only receive medical treatment they need. 

Cost of Provider Network

The monthly premium for a provider network is usually lower than typical insurance. The cost varies from company to company and is largely dependent on how big the network is and how varied the medical providers in it are.

Costs of Using Provider Network

One of the benefits of using a provider network is the lower copayments and deductible when you use a doctor that is in-network. The costs can be drastically lower in some instances. This is the primary reason people choose to enroll in a provider network.

Cost of Using an Out of Network Provider

Those enrolled in a PPO or an HMO can plan still see out-of-network doctors, but their portion of the shared cost will be higher than if they use one in their network. This is to encourage those enrolled in a provider network to see doctors who are in-network and help keep costs down for both parties. 

What to Do if a Doctor Isn't in a Plan's Provider Network

If you wish to see a doctor who isn't in your network, contact your insurance company to see if your policy has an out-of-network option. If it does, you can move forward with the doctor and pay the higher costs associated with it. If you don't have an out-of-network option, you will have to pay the full costs for the medical services.