Out of Network Health Coverage for Diagnostic Medical Tests, Lab and X-Rays

UPDATED: Jul 15, 2023Fact Checked

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Jeffrey Johnson

Insurance Lawyer

Jeffrey Johnson is a legal writer with a focus on personal injury. He has worked on personal injury and sovereign immunity litigation in addition to experience in family, estate, and criminal law. He earned a J.D. from the University of Baltimore and has worked in legal offices and non-profits in Maryland, Texas, and North Carolina. He has also earned an MFA in screenwriting from Chapman Univer...

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Mary Martin

Published Legal Expert

Mary Martin has been a legal writer and editor for over 20 years, responsible for ensuring that content is straightforward, correct, and helpful for the consumer. In addition, she worked on writing monthly newsletter columns for media, lawyers, and consumers. Ms. Martin also has experience with internal staff and HR operations. Mary was employed for almost 30 years by the nationwide legal publi...

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UPDATED: Jul 15, 2023

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UPDATED: Jul 15, 2023Fact Checked

You go to the doctor on your insurance carrier’s list of participating physicians for a routine physical, and he orders x-rays and lab work performed in an out of network facility. You find out that your insurance carrier approved the doctor’s visit, but the follow-up diagnostics were not covered at all under your existing policy and you unwittingly become responsible for the daunting bills. You are floored and question whether you have to ante up.

In short, if you received the health care services, you are on the hook for the bill. You have a responsibility to be proactive in your own care. YOU need to make sure your doctors know which labs participate with your health insurance plan, so they can send your tests to the right place.

And if you are going outside the doctor’s office to get the tests done, then you need to check with your insurance carrier on where you can go – do not rely on your doctor to know. You should understand that your doctor has many patients with lots of different health insurance plans. He cannot possibly be expected to know the nuances, coverage limits and networks of every plan by heart. You are only one patient, with one health insurance plan, and it is your responsibility to become familiar with every aspect of that plan, if you want to make sure your bills are paid correctly.

Too many patients assume that their plan is too complicated to understand and think their doctor will just “know”, and that is how they end up in such situations with unexpected expenses. In the future, you can avoid this by getting the list of in-network labs and diagnostic facilities from your insurance company’s web site, or ask them to mail you a catalog. This way, the next time you need a test done, you will know where to go if you want to remain in network, and you can research what portion your own provider will cover and understand your financial exposure if you go out of network.

Case Studies: Out of Network Health Coverage for Diagnostic Medical Tests, Lab, and X-Rays

Case Study 1: Unexpected Bills for Out-of-Network Diagnostics

You go to the doctor on your insurance carrier’s list of participating physicians for a routine physical, and he orders x-rays and lab work performed in an out-of-network facility. You later discover that your insurance carrier approved the doctor’s visit, but the follow-up diagnostics were not covered under your existing policy. As a result, you are left responsible for the overwhelming bills.

Case Study 2: Lack of Provider Knowledge Leads to Uncovered Expenses

Assuming your doctor knows the details of your health insurance plan can lead to costly surprises. In this case, a patient relied on their doctor’s knowledge regarding in-network labs and diagnostic facilities. However, the doctor, who deals with various health insurance plans, could not possibly be expected to know the nuances, coverage limits, and networks of every plan by heart. Consequently, the patient ended up with unexpected expenses.

Case Study 3: Taking Responsibility for Your Healthcare

Patients often assume their insurance plans are too complicated to understand and rely solely on their doctors for information. However, this approach can result in unfavorable outcomes. To avoid such situations, it’s crucial to become familiar with every aspect of your health insurance plan. By obtaining a list of in-network labs and diagnostic facilities and researching coverage limits and financial exposure, you can make informed decisions and prevent unexpected bills.

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Jeffrey Johnson

Insurance Lawyer

Jeffrey Johnson is a legal writer with a focus on personal injury. He has worked on personal injury and sovereign immunity litigation in addition to experience in family, estate, and criminal law. He earned a J.D. from the University of Baltimore and has worked in legal offices and non-profits in Maryland, Texas, and North Carolina. He has also earned an MFA in screenwriting from Chapman Univer...

Insurance Lawyer

Mary Martin

Published Legal Expert

Mary Martin has been a legal writer and editor for over 20 years, responsible for ensuring that content is straightforward, correct, and helpful for the consumer. In addition, she worked on writing monthly newsletter columns for media, lawyers, and consumers. Ms. Martin also has experience with internal staff and HR operations. Mary was employed for almost 30 years by the nationwide legal publi...

Published Legal Expert

Editorial Guidelines: We are a free online resource for anyone interested in learning more about legal topics and insurance. Our goal is to be an objective, third-party resource for everything legal and insurance related. We update our site regularly, and all content is reviewed by experts.

Free Insurance Quote Comparison

Enter your ZIP code below to compare cheap insurance rates.

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