How to Use Out-of-Network Benefits for Pain Management in New Jersey

If your health plan has out-of-network benefits, you can usually see a pain management doctor who is not in your plan’s network and still have part of the cost paid by your insurer. How much depends on your plan’s out-of-network deductible, its coinsurance and the amount it allows for each service. The quickest way to find out is to have the practice check your benefits before you book.

That’s what we do at Montville MedSpa & Pain Center. We are an out-of-network provider for pain management, and before anything is scheduled our team calls your plan and tells you what to expect.

The rest of this post explains what the words on your insurance paperwork mean, so the answer makes sense when you hear it.

What does “out-of-network” actually mean?

Insurers sign contracts with a list of doctors, called the network. Those doctors agree to the insurer’s set rates. A doctor who has not signed that contract is out-of-network.

Seeing an out-of-network doctor is allowed on many plans. The plan simply treats the visit under a different set of rules, which you’ll find on your summary of benefits under a heading like “out-of-network” or “non-participating provider.”

Some plans, often HMOs and EPOs, pay nothing out-of-network except in emergencies. PPO and POS plans more often include out-of-network coverage. The type of plan is usually printed on your card, but the card alone won’t tell you the details.

Who tends to have out-of-network benefits?

We hear from a lot of people who had no idea they had them. Teachers, police officers, firefighters, and town, county and state employees in New Jersey often have plans that still include out-of-network coverage. So do some people with plans through larger private employers.

These are also the jobs that are hard on the body. Hours standing in a classroom, gear worn through a long shift, years of driving or lifting. Back, neck, knee and shoulder pain come with the territory, and many people put up with it because they assume the specialist they want isn’t covered.

It’s worth a phone call to find out.

What do deductible, coinsurance and “allowed amount” mean?

These three words decide most of what you pay.

Your out-of-network deductible is what you pay yourself each year before the plan starts sharing costs for out-of-network care. On many plans it is separate from the in-network deductible, so money you spent seeing in-network doctors may not count toward it.

Coinsurance is the share you pay after the deductible is met. Your plan pays the rest of its share.

The allowed amount is the figure your plan decides a service is worth. The plan works out its payment from that number, not from the doctor’s bill. If the bill is higher than the allowed amount, the difference may be yours to pay.

There is often also an out-of-pocket maximum for out-of-network care. Once you reach it, the plan pays its full share of covered services for the rest of the year.

Put together, two people with the same procedure can have very different costs. That is why we don’t quote a percentage or a typical figure. We check your actual plan.

What should I ask my insurance company?

If you’d like to call your plan yourself first, these questions get you useful answers:

Do I have out-of-network benefits for specialist visits and outpatient procedures?

What is my out-of-network deductible, and how much of it have I met this year?

What is my coinsurance for out-of-network care?

Is there an out-of-network out-of-pocket maximum, and how close am I to it?

Do pain management injections need prior authorization?

Write down the name of the person you spoke to, the date and a reference number for the call. If something is disputed later, that note helps.

Do I need a referral?

Not to see us. You can call and book a consultation with Dr. Donna D’Alessio directly.

Your plan may have its own rules about referrals or prior authorization for certain procedures, which is one more thing our team checks when they look at your benefits.

How does the claim get filed?

We file the claim with your insurance on your behalf, so you are not left filling out forms and mailing receipts.

Afterwards your plan sends you an Explanation of Benefits. It is a statement and not a bill. It shows what was billed, the allowed amount, what the plan paid and what it says is your share. If something on it doesn’t match what you were told, call us and we’ll look at it with you.

Why see an out-of-network pain doctor at all?

Because the right diagnosis matters more than the network directory.

Dr. D’Alessio is board-certified in Physical Medicine & Rehabilitation, the specialty built around restoring function without surgery. Your first visit is an examination and an explanation of what is actually causing the pain. Treatment for back pain, neck pain, sciatica and joint problems is paired with a plan to get you moving again, so the relief lasts.

Being out-of-network also means the appointment is not built around an insurer’s visit schedule. She has time to listen and examine you properly.

If you’ve had the same pain for months and tried the usual routes, that is the situation where using benefits you already pay for makes sense. You can read more about how we approach it on our pain management page.

Frequently asked questions

Will my out-of-network benefits cover pain injections?

It depends on your plan. Many plans cover medically necessary pain treatment out-of-network, but some need prior authorization or have limits. We check before anything is scheduled.

Does out-of-network always cost more?

Often your share is higher than it would be in-network, but not always by as much as people expect, especially if you have already met your out-of-network deductible for the year. Your actual numbers are the only reliable guide.

What do I need to have ready when I call?

Your insurance card, front and back, and your date of birth. If you’re not the main policy holder, the policy holder’s name and date of birth as well.

I’m a teacher (or police officer, or state employee). Is it worth asking?

Yes. These are the plans that most often still carry out-of-network benefits, and many people with them have never used them.

Call us in Montville

If you have back, neck, joint or nerve pain and think you might have out-of-network benefits, call Montville MedSpa & Pain Center at (973) 794-3958 with your insurance card. We’re at 624 Main Rd in Towaco, Montville Township, and our team will check your coverage and tell you what to expect before you book a consultation with Dr. D’Alessio.