Choosing In-Network vs. Out-of-Network Providers for Rehabilitation

by | Jan 3, 2022 | Drug Recovery | 0 comments

Rehabilitation programs play a significant role in every stage of recovery, so choosing in-network or out-of-network providers for rehabilitation becomes a crossroads. Selecting the right treatment center is crucial for not only reaching recovery but also for giving you the resources and support you need to sustain recovery for the long term. If you are struggling with substance use disorder (SUD) and ready to explore your options for treatment, you likely have several questions about how to proceed. After making the decision to seek treatment, the next obstacle you must overcome is determining how to pay for your care.

Health insurance companies provide access to necessary health services and are meant to offer financial protection from exorbitant health care costs. However, these companies are for-profit businesses with their own goals. They are motivated to save as much money as possible when they can, and they often have limited networks of providers they cover to save on costs. Your insurance company will encourage you to visit the providers in their network, but this may not always be the right option for you.

When your insurance company pushes you in one direction, but research indicates you may receive a higher quality of care from providers outside of this network, which do you choose? What are the differences between in-network or out-of-network insurance, and how do you make the best decision for your recovery?

Insurance-Based Substance Use Disorder Treatment

In an ideal world, everyone would have unrestricted access to the health care services they need without worrying about financial constraints. However, for many people, this is not reality. In most cases, the cost of treatment for substance use disorder is determined by your insurance plan. You must determine whether the plan covers SUD treatment, the types of treatment it covers (detox, inpatient, outpatient, etc.), how much of this treatment your insurance company is willing to cover, and for what amount of time. Although price should not be the sole deciding factor when choosing a rehab facility, it is important to understand your options and what your insurance will cover so you can select the right SUD treatment program for you.

Some insurance companies negotiate pre-arranged deals with rehab facilities where the care provider can offer patients treatments at predetermined rates. These facilities are referred to as “in-network,” and the facilities that do not have predetermined rates are “out-of-network.” Depending on your insurance plan, you may have a variety of rehab facilities in your network, meaning your insurance will cover all or a portion of your care at these facilities. However, because both health insurance companies and rehab facilities are for-profit businesses, these in-network providers are almost always forced to sacrifice their quality of care or the length of stay they can offer you, at a center so they can afford the rates set by the insurance companies.

In-Network vs. Out-of-Network Insurance for Rehab Treatment

While this does not apply to every care provider, there are four main differences between in-network and out-of-network rehab treatment facilities.

Out-of-Network Rehabs Tend to Cost More, but Not Always

When insurance companies negotiate contracts with in-network SUD treatment facilities, the rates for treatment are generally lower than out-of-network providers. Out-of-network rates can be two or three times higher—or more—than in-network rates. Even if a patient and their family can save up for the first few months of treatment, paying for continuing care can become increasingly difficult. Because the duration of treatment has a significant impact on patient outcomes, financial concerns can serve as a serious obstacle to sustaining recovery. However, this is not always the case. Sometimes, you can spend as much on deductibles and co-pays with an in-network provider as you would spend for treatment at an out-of-network facility. Carefully review your insurance plan to determine which option is more affordable or call Illuminate Recovery and we can help you understand your plan.

Compare In-Network vs. Out-of-Network Insurance

In-Network Rehabs May Offer Less Control Over Treatment

Lower costs can benefit patients by making treatment more affordable and more accessible, but this reduced cost can have its disadvantages. In exchange for securing a contract that allows them to be part of an insurance company’s network of providers, these facilities are often far more limited in the treatment options they provide than out-of-network facilities. Contracts stipulate what types of treatment are covered by the insurance plan, determine the dollar amount they are willing to cover, and outline standards for when a patient is considered “rehabilitated enough” to no longer need SUD treatment.

Reduced control over treatment and less qualified providers can result in limited and/or poorer quality treatment that only addresses the SUD. As a result, treatment can lose focus of the entire person and any dual diagnoses that may affect their treatment. Patients who experience other mental health issues will be forced to seek outside behavioral therapy in combination with the SUD treatment program. Other issues that may arise within in-network provider programs include strict requirements for additional authorizations to continue treatment after a certain period, the need to fight with insurance companies for adequate coverage and other uncovered costs. In some cases, it can mean that you will be discharged before you are truly ready to sustain recovery on your own.

In-Network Rehabs Often Have Less Qualified Care Providers

To further save costs, in-network rehab facilities may also employ less qualified staff members rather than service providers with master’s or doctorate level therapy training and independent professional licenses. In other words, you could be receiving care from staff members that would not legally be allowed to provide similar services outside of the facility’s program. This is the reason many in-network care providers are limited to inpatient, residential, partial hospitalization, and intensive outpatient programs. These services are billed with the facility’s information instead of the individual provider’s information.

Out-of-Network Rehabs Often Have More Resources

 Out-of-Network Rehabs Often Have More Resources

To make money, many in-network rehab providers practice a “quantity over quality” approach to SUD treatment services—they have fewer resources to invest into their program and patient care. In contrast, because out-of-network providers are not restricted by contracts that specify procedures or place limits on the type of care they can provide, they have more resources available. This allows them to implement effective, evidence-based treatment rather than simply providing the level of care they can afford under the terms set in their contract with the insurance companies. Out-of-network facilities usually have smaller waitlists and offer higher quality of care, which can lead to better patient outcomes.

Questions to Ask Your Insurance Provider

Every insurance plan is different, so the best way to determine what your plan covers is to call your insurance company and ask them directly. The following questions can help you prepare for substance use disorder treatment:

Does my insurance plan cover detox, inpatient rehab, and aftercare services?

In many cases, insurance providers fully cover SUD assessment and preventative care and mostly cover the cost of detox and outpatient programs. However, your provider may only offer partial coverage for inpatient (residential) programs. First, explore your treatment options with your doctor to determine what they recommend, then speak with your insurance provider to find out how much you will be expected to cover out of pocket when paying for treatment.

Questions to Ask Rehab Service Providers

Questions to Ask Rehab Service Providers If the care provider accepts your insurance, ask:

  • Are you in-network with my current insurance plan?
  • Do members of your staff have the credentials to bill insurance individually?
  • After I complete inpatient, residential, PHP, or IOP, do you offer long-term aftercare services that are covered by my insurance plan?
  • When can I receive these services?
  • How do you determine the required care level for patients?
  • Do you offer short-term healthcare financing or interest-free payment plans?

If you plan to self-pay for a SUD treatment program out-of-network, ask:

  • Are your direct service providers professionally licensed?
  • Do you charge for the program or for each service rendered?
  • If I leave the program early or get discharged, what do you do with my deposit and money that I have already paid for treatment?

In-Network or Out-of-Network Insurance – Which Option Is Right for You?

The types of payment methods a facility accepts can seriously impact the ability of patients to continue treatment that achieves better long-term outcomes. In general, a facility’s decision to contract its services with insurance companies can dictate the structure of a program and the overall quality of care patients can expect.

Typically, the greater access a program offers, the lower the quality of treatment, but this is not always the case. Some programs are more effective than others at balancing the financial concerns of the facility with a patient-first mission.

Price should not be the only factor you consider when choosing a rehabilitation facility. If you are exploring your options for SUD treatment, remember that you must do what is best for your recovery, not just your budget. For the best chance of sustaining recovery, you need a program that combines both medical and evidence-based therapeutic services and addresses your unique needs beyond substance use disorder.

Ensure the facility employs professionally licensed care providers and facilitates long-term recovery at the appropriate care levels. By understanding the differences between in-network vs. out-of-network insurance for rehab and asking the right questions, you can make sure you are in the best possible facility to support your long-term recovery.

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