In-network doctor vs out-network clinic/hospital ?

Question

As a foreign student visiting US, America's
insurance and health care system seems ridiculous complicated for me.

Especilaly I'm confused with some cases when doctor and clinic
are not in the same "network", one is in-network, one is out-network.

If I visited a doctor whose name I found from insurance
company website, then the doctor is in-network,
but the clinic he/she works is out-network.

Then I was charged extra fee of the clinic which will not
be covered by insurance company (docotor'serive was reimbursed
by insurance).

In the other case, I found an in-network clinic or hosiptal,
but as the clinic, I was treated by a doctor whose
name couldn't be found on insurance company' website,
so the doctor is out-network. His service could not be covered
by insurance company.

Are these two experience reasonable and possible ?

So I want to get a full insurance coverage,
do I have to be treated by an in-network doctor,
at an in-network clinic/hosiptal ?

Answer 1

Welcome to the world of health insurance. I have worked in this industry for 8 years now. Networks are complicated but the best thing to do is to call you customer service dept with your insurance company...number should be on your card. Doctors have to sign up for network participation and so do hospitals and clinics. Sometimes in emergency situations, cases can be forgiven but please call your insurance company for a better understanding of your particular situation and your policy.

Answer 2

You questions are best addressed by your health insurance provider. Once you were enrolled, you should have received in the mail documentation as to your benefits and limitations and your responsibilities concerning out-of-network coverage. Maybe you threw this out or just set it aside. What you have described no doubt makes sense from an insurance point of view.

My suggestion is that you call the customer service number on your insurance card and direct your questions to your insurance company. They will be happy to explain everything to your satisfaction and understanding.

Answer 3

You must be in Florida. Yes, both of these situations are possible. Ideally, you want to find a clinic or hospital where both, the doctors and the staff along with the clinic , are all in the network.