Helping Employees with Out-of-Network Claims & Appeals
Even the most well-designed benefit plan can run into issues—especially when employees receive care from an out-of-network provider. In these cases, understanding how to navigate the claims and appeals process can make a big difference in reducing financial stress. As an employer, you can play a key role in supporting your employees when they face these situations.
What Does “Out-of-Network” Mean?
An out-of-network provider is a doctor, hospital, or healthcare facility that does not have a contract with the insurance company. Because there’s no pre-negotiated rate, the costs are usually higher—and employees may be balance billed for the difference between what the provider charges and what the plan pays.
Steps Employees Can Take
Double-check provider network status** before scheduling appointments.
Ask for pre-authorization or referrals** when needed.
Request an itemized bill** from the provider to ensure accuracy.
File a claim manually** with the carrier if the provider does not.
Appeal denied claims** by submitting a formal request with medical justification or supporting documents.
How Employers Can Help
Educate employees during open enrollment about the importance of staying in-network.
Provide access to customer service numbers or your broker to assist with tricky claims.
Offer a simple claims checklist or template for submitting out-of-network documentation.
Encourage employees to speak with their provider’s billing office for potential discounts.
Tips for Open Enrollment Season
Include a session or handout that explains how out-of-network billing works.
Review current claims data with your broker to identify trends or recurring provider issues.
Make sure employees know which networks are tied to your plans.
Consider plan designs with stronger out-of-network protections if you have a mobile or remote workforce.
Claims issues can be frustrating and stressful—but with the right information and support, your employees can navigate them with confidence. And as their employer, your guidance and resources can go a long way in making the process feel less overwhelming.
To learn more, contact the Frost / Beck Insurance Agency. Call us at 419-592-4476, send an email to frost@frostins.com, or click here to submit your request today! Alternatively, stop by and see us at one of our four convenient locations in Archbold, Napoleon, Holgate, or Whitehouse.
Coming next week, we will explore the role of telemedicine and virtual care in today’s benefits plans.