The real problem with going somewhere out of network is that you don't have protection against balance billing.Let's say you go to an in network provider who would charge $1000 for a procedure. Your insurer might have a contract to pay $200 for it. The contract also typically provides that the in network provider must accept that $200 for the whole thing and can't charge you for the balance (the $800). So - from your standpoint as a patient - it's all good. This even works if you are still in your deductible. Let's say you had a $500 deductible. All the in net work provider could get from you would be the $200 that the insurer would have paid if you weren't still in your deductible.Now, let's say you go to an out of network provider who would charge $1000 for a procedure. Your insurer has no contract with that provider. However, your insurer will only pay what it considers a reasonable amount. That would typically be something like the $200 it would pay to an in network provider. So your insurer (assuming you have met your deductible) sends $200 to the out of network provider. But, the out of network provider (having no contract with your insurer) will then balance bill you for $800. You might be able to negotiate something lower or might not.So - if it was me - I would not be going to the out of network clinic that your PCP referred you to. Find out who would be in network for the specialty in question and have your PCP refer you to someone in network.
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