Is the physician or hospital “participating,” “approved,” or “in network”?
Some plans, especially HMOs and PPOs, either require you to receive care from a doctor, healthcare provider, or entity who has signed a contract with the payer, or make you pay more money for using a doctor who is not in the plan. Let’s say, for example, your doctor participates in your insurer’s PPO. The insurance may pay 80% and you would be responsible for paying the remaining 20%. However, if you are treated by a doctor who is not a participating provider, your payer may cover less than 80%—probably closer to 60% (of the reasonable and customary charges). That would mean you would be responsible for paying the remaining 40% of the bill.
