The insurance maze begins....

On the question you asked:

When your doctor suggests a test/procedure, as you book with their scheduler, ask them if they will be running it by your insurance company.  They typically have a staff member whose job includes making those insurance company contacts/getting preapprovals.  You might discover that they want you to have some other test first, and then they'll cover it.  That they need a letter citing "medical necessity" from your doctor. Or some other "hoop" you need to jump through before they'll approve whatever it is your doctor is recommending.  Or you may end up needing to use their formal appeal process (but use the informal steps first...).

You didn't ask, but I thought I'd mention that if you're going to be using an out-of-network PS, you may be paying more than the "additional 20%."  Additional charges can come from at least three places that I can think of.  

1.  Higher deductible for out-of-network providers.  If, for example, you've already met an in-network deductible of $2,000, so the insurance company will be paying 100% of your remaining in-network charges this year, when you go out of network, you may need to meet an additional deductible before your insurance will pay dollar #1.

2.  "Usual and customary charges."  The percentages that your insurance company says they will pay are a percentage of the usual and customary charges for whatever the services/procedures that you're having.  And the insurance company says what the usual and customary charges are (based on surveys and other methods).  The in-network doctors agree that they will accept the insurance company's usual and customary payments as payment in full.  However an out-of-network provider hasn't agreed to limit their payment to the insurance company's usual and customary number.  And they usually don't.  So if the insurance company's U&C amount for a procedure is $100, your coverage is 70%, and your out-of-network deductible has been paid, then the insurance company will pay $70.  But the doctor charged $200.  You'll be paying $130.  And if you haven't met your out-of-network deductible yet, then only the $70 will count toward meeting the out-of-network deductible, but you'll owe the doctor $200.

3.  An out-of-network doctor may work with other out-of-network resources (hospitals, labs, anaesthesiologists, etc.) all of whom will also be more expensive.

So if you decide to use an out-of-network provider, I'd ask to sit down with their financial person first to sort out what your costs will be.

HTH,

LisaAlissa