What happens if a non-member physician is utilized under a Point of Service plan?

When a non-member physician is utilized under a Point of Service (POS) plan, the correct outcome involves the patient facing a higher coinsurance amount. This is because POS plans offer a combination of managed care features and the flexibility of going outside the network.

When beneficiaries receive care from non-network providers, while they do have the option to do so, they generally incur higher out-of-pocket costs compared to using in-network providers. This includes a higher coinsurance rate, which is the percentage of the cost of care that the patient is responsible for after the deductible has been met.

This structure is designed to encourage patients to utilize in-network providers, which are negotiated at lower rates based on the agreement between the health plan and the physicians, thereby helping to manage overall healthcare costs for both the insurer and insured.

Choosing a non-member physician does not mean the insurance will refuse coverage entirely, nor does it equate to the attending physician receiving unspecified payments or the patient paying no extra. Therefore, the increased coinsurance charge is reflective of the additional costs and out-of-pocket expenses associated with seeking care outside the established network of providers.