13:14 PM

Know Before You Go: New Tool Shows You Out-of-Pocket Costs for Out-of-Network Care



High and unexpected health care costs are hard to handle. Avoid sticker shock by using our out-of-network cost calculator.

By Thomas Vincz, Public Relations Manager

Health care can be expensive, especially when you choose to see a doctor or seek treatment at a facility that doesn’t accept your health insurance. While recent changes to New Jersey state law are preventing out-of-network doctors from passing along outrageous surprise bills, patients who choose an out-of-network doctor remain unprotected.

Your best protection against getting a medical bill that looks more like a new-car sales sticker than one for an in-office procedure is to see health professionals in your insurance network. Health insurers negotiate reimbursement fees upfront with the doctors who participate in their networks, which allows them to limit your out-of-pocket costs to your co-pay or coinsurance once you’ve met your deductible.

If you do choose to see an out-of-network doctor, a little research upfront can help you avoid sticker shock.

To help members avoid high and unexpected health care costs, Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) offers online and mobile price transparency tools that let members see an estimate of the charges they’ll likely see from doctors, specialists, care facilities or labs that do not participate in Horizon BCBSNJ’s network.

Horizon BCBSNJ’s new tool is called the out-of-network cost calculator. This estimator gives users a 360-degree view of their medical costs – from what is paid out-of-pocket by a patient to what reimbursement is received by the non-participating provider.

Here’s how it works. If you want to get cost estimates for an upcoming visit or procedure with a health professional or facility, the tool lets you drill down to the member’s out-of-pocket expenses for that care.

Here is what you do after clicking on the estimator:

  • Enter your zip code so that the estimator can search for and calculate charges within a specific geographic area.
  • Specify the type of clinical service or procedure you are seeking.
  • The tool then generates an estimate by tapping a database maintained by FAIR Health – a national, independent nonprofit organization whose mission is to bring transparency to health care costs. FAIR Health’s estimate is based on over 31 billion billed procedures from plans covering more than 150 million individuals in the health care system.
  • The tool provides you an estimated cost of the procedure, along with an estimate of what your out-of-pocket costs would be from a provider who is not in Horizon’s network.

Some of these costs can be eye-popping, such as $4,165 to treat a broken finger in a New York City zip code. That’s what someone paying out-of-network, or without insurance, would be billed for a relatively simple procedure.

For members who decide the cost of care out-of-network is more than they can stomach, Horizon BCBSNJ’s Doctor and Hospital Finder offers a user-friendly guide to locating providers nearby who accept their insurance.

Available on HorizonBlue.com and the Horizon Blue App, the tool tells you how to find in-network providers by location, specialty, and other searchable criteria. Horizon BCBSNJ members with OMNIA Health Plans can also see which are Tier 1 or Tier 2. Seeing an OMNIA Tier 1 provider means lower out-of-pocket costs.

By logging into your Horizon account through Horizon BCBSNJ’s home page, www.HorizonBlue.com, members can also access the Treatment Cost Estimator located in the Benefits & Coverage section.

Like the out-of-network cost calculator, the Treatment Cost Estimator allows you to compare prices for office visits, procedures, surgeries and tests. You can also conduct searches based on where you live and what specialty you are seeking. Tied directly with your specific coverage information, including whether you have satisfied your deductible, the estimator gives you real-time information on what the procedure costs and what obligation, if any, you have out-of-pocket.

Whether planning a procedure at a hospital, screening at an outpatient facility or a consult with a specialist, the best – and easiest – way to take control of your health costs? Know before you go.