Do healthcare providers have more leeway for treatment options if they are out-of-network?

One of my wife’s doctors is converting to a private practice that is out-of-network (for all insurance plans) next month. This is extraordinarily frustrating for us, since she’s been in the queue for surgery for the better part of this entire year, and she finally got scheduled for the first week in January.

I’ll spare everyone the details of all the savings, planning, and health insurance research we did during enrollment this year in anticipation of this surgery, and how the additional out-of-pocket maximum for out-of-network really throws all those plans out the window..

In the announcement letter we received in the mail today, the doctor claims that they are making this move because:

Being out-of-network means we aren’t limited in the treatments we can provide. This arrangement allows us to offer comprehensive, personalized treatment plans determined by your specific health needs and not the whims of insurance companies.

Now if you ask me, that seems like a load of marketing crock. I’m certainly no insurance expert, but I have tried to research how these costs and payments all work together, and I think I’ve acquired a decent understanding over the years.

Does this claim of more “treatment freedom” make any sense? If insurance wouldn’t cover the claim for an in-network provider, why would moving to out-of-network somehow make that claim be covered (though at a higher out-of-network rate for the patient)? Processing a claim as out-of-network isn’t some sort of magic bullet that lets you get coverage for anything you want. It seems like treatments would be even more likely to be denied by insurance. And if the treatment is being denied in either case, why can’t the provider just stay in-network and charge the patient for what insurance doesn’t cover? After all, that’s what’s going to happen with the move to out-of-network anyway.

Am I completely ignorant in this situation? Does moving out-of-network truly allow this doctor to provide better care, that would otherwise be limited by being in-network? Or am I seeing this claim for what it truly is: a PR statement that avoids saying they just want more money?

I’ve also realized I’ve intermingled the term “claim” for both what the doctor is stating in his letter, as well as the typical usage for health insurance claims. But now that I think about it, I’m gonna go ahead and mark this doctor’s claim as DENIED until proven otherwise..

submitted by /u/BeardedSpruce
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One of my wife’s doctors is converting to a private practice that is out-of-network (for all insurance plans) next month. This is extraordinarily frustrating for us, since she’s been in the queue for surgery for the better part of this entire year, and she finally got scheduled for the first week in January. I’ll spare everyone the details of all the savings, planning, and health insurance research we did during enrollment this year in anticipation of this surgery, and how the additional out-of-pocket maximum for out-of-network really throws all those plans out the window.. In the announcement letter we received in the mail today, the doctor claims that they are making this move because: Being out-of-network means we aren’t limited in the treatments we can provide. This arrangement allows us to offer comprehensive, personalized treatment plans determined by your specific health needs and not the whims of insurance companies. Now if you ask me, that seems like a load of marketing crock. I’m certainly no insurance expert, but I have tried to research how these costs and payments all work together, and I think I’ve acquired a decent understanding over the years. Does this claim of more “treatment freedom” make any sense? If insurance wouldn’t cover the claim for an in-network provider, why would moving to out-of-network somehow make that claim be covered (though at a higher out-of-network rate for the patient)? Processing a claim as out-of-network isn’t some sort of magic bullet that lets you get coverage for anything you want. It seems like treatments would be even more likely to be denied by insurance. And if the treatment is being denied in either case, why can’t the provider just stay in-network and charge the patient for what insurance doesn’t cover? After all, that’s what’s going to happen with the move to out-of-network anyway. Am I completely ignorant in this situation? Does moving out-of-network truly allow this doctor to provide better care, that would otherwise be limited by being in-network? Or am I seeing this claim for what it truly is: a PR statement that avoids saying they just want more money? I’ve also realized I’ve intermingled the term “claim” for both what the doctor is stating in his letter, as well as the typical usage for health insurance claims. But now that I think about it, I’m gonna go ahead and mark this doctor’s claim as DENIED until proven otherwise..
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