Out-of-Network Plans

WVU Medicine is committed to providing patients with the information they need to make informed decisions about their care. While many health insurers provide their members with full, in-network access to WVU Medicine, there are certain types of health insurance plans and other products, including those that use unilateral repricing, that do not. Unilateral repricing plans and health sharing plans are out-of-network with WVU Medicine hospitals and facilities.

When WVU Medicine refers to a unilateral repricing plan — sometimes called a “reference-based pricing” plan — it means a plan that, as a general rule, chooses not to contract with hospitals or healthcare facilities. Rather, these plans decide unilaterally how much to pay out-of-network hospitals or facilities for a patient’s care. When these plans pay the hospital, facility, or doctor less than the amount owed for that care, they put the patient in the middle of a billing dispute. These plans force healthcare providers to recover any unpaid amounts (beyond co-pays, co-insurance, or deductibles) directly from the patient.

WVU Medicine may require payment in advance from patients who want to schedule out-of-network care.

Below are some frequently asked questions regarding out-of-network and reference-based pricing plans.

What is a health sharing plan?

Health sharing plans are arrangements where a group of individuals come together to share medical expenses. These plans are not considered insurance and do not contract with WVU Medicine hospitals or healthcare facilities. They are not subject to the Affordable Care Act and therefore may not offer the same protections, such as minimum essential coverage or caps on out-of-pocket costs. They also are not bound by the same regulations as traditional insurance plans and can deem care an “unshared” expense that passes the cost along to the member as well as exclude pre-existing conditions.

What does “out-of-network” mean?

A WVU Medicine hospital, facility, or physician that has no contract with your insurance company or health plan administrator — which could be a third-party administrator, or “TPA” (see below) — is referred to as “out-of-network.”

What is a third-party administrator (often referred to as a TPA)?

A third-party administrator delivers various services on behalf of health insurance plans — often self-insured health plans — which may include the design, launch, and management of the health plans. Some TPAs are now using unilateral repricing plans to set costs without provider input; however, because these plans do not contract with hospitals and facilities to provide their members care at in-network rates, their members are finding themselves out-of-network at many hospitals, including WVU Medicine.

My plan administrator tells me that I can “go wherever I want” with my health insurance plan. Does that mean I am in-network at WVU Medicine?

No. While some unilateral repricing plans and health sharing plans say that plan members are free to go to any hospital or doctor, that does not mean that your care will be in-network. If your plan does not have a contract with a WVU Medicine hospital, facility, or doctor, your care will be out-of-network and you may be required to pay in advance for nonemergent care.

What should I ask my insurance company or health plan to find out if WVU Medicine is out-of-network?

It is important to ask whether the specific WVU Medicine hospital, facility, or physician is “in-network.” You can reach out to your plan directly, using the number on your card. If your insurance is provided through your employer, you may also want to direct this question to your employee benefits representative.

Does WVU Medicine have a list of plans that are out-of-network at WVU Medicine?

Yes. Because we want our patients to have as much information as possible about their access to WVU Medicine care and services, we list the products we have identified as out-of-network.

Please note: If a plan is not listed, that does not mean that it is in-network. The best way for a member to check provider network status is to ask their plan.

Remember: You need to ask if the WVU Medicine provider is in-network with your plan. Your plan administrator telling you that you can “go to WVU Medicine” is insufficient and might result in you being personally responsible for unpaid out-of-network bills.

How do I access out-of-network care at WVU Medicine?

WVU Medicine may require payment in advance for out-of-network nonemergent services. If a patient wants to schedule out-of-network care that is nonemergent — such as same-day surgery or advanced radiology — WVU Medicine will provide them with an estimate of these costs. We may ask for a deposit on the total amount due from the estimate. For out-of-network physician office visits, WVU Medicine may collect a self-pay pre-payment.

How do I get an estimate for the cost of out-of-network services at WVU Medicine?

To ensure that you understand your financial responsibilities before scheduling services, you can call a WVU Medicine financial representative at 304-974-3540. They will be able to give you an estimate for the care you are interested in scheduling. You can also create an estimate through MyWVUChart using your login or as a guest.

Can I make a partial payment or set up a payment plan for my scheduled care at WVU Medicine?

WVU Medicine does accept partial payments in the form of deposit amounts prior to service (typically 20 percent) or can arrange a payment plan for amounts due beyond the deposit, depending on the service that is being rendered. Required deposit amounts are due in full and in advance of services. If your service requires a deposit, a financial representative will contact you.

Will I have to pay more than the advance payment?

If the care provided ultimately costs more than the pre-payment amount, you will receive a bill in the mail or through MyWVUChart for any additional amounts due. It will be your responsibility to pay the additional amounts in a timely manner, even if those additional services were not planned or were not included in the original estimate you received.

Will I need to pay in advance for office visits with my WVU Medicine physicians, like my primary care doctor?

It will depend on your specific health plan. Some companies that use unilateral pricing offer plans that are out-of-network for WVU Medicine hospitals but in-network for WVU Medicine physicians in outpatient offices.

If your plan does not provide in-network access for office visits, WVU Medicine may collect a pre-payment for out-of-network physician office visits.

Are there any exceptions or alternatives to pre-payment?

Yes. Pre-payment is not required for the following:

  • COVID-19 — Care and treatment related to a possible or confirmed case of COVID-19
  • Emergency care — All patients, regardless of insurance coverage or the lack of insurance, who present to any WVU Medicine Emergency Department for care will receive an appropriate medical screening examination and any stabilizing care necessary for their emergent condition
  • Pediatric care — Care and services provided at WVU Medicine Children’s Hospital

Even if pre-payment is waived, patients who receive out-of-network care at WVU Medicine will still be financially responsible for the costs of the out-of-network care they receive and will be balance-billed for any out-of-network amounts owed that their health insurance plan fails to pay.

In some cases, patients may be able to request that their health insurance plan pursue a single-case agreement with WVU Medicine for a specific scope of care.

What is balance billing?

Balance billing is a medical bill from a healthcare provider sent after care has been provided. The amount of the bill is the difference between the total cost of services and the amount the health insurance paid or the amount that was paid in advance. Even though WVU Medicine may collect payment in advance for out-of-network services based on an estimate, patients may have an account balance following the out-of-network care and will receive a balance bill in the mail or via MyWVUChart.

For more information about out-of-network products at WVU Medicine, please visit the Frequently Asked Questions page.

If you have additional questions, please call our help line at 304-974-3540.

What other options do I have to obtain healthcare insurance?

One option to obtain healthcare insurance is from the government exchange at www.healthcare.gov. Subsidies may be available dependent on income. WVU Medicine’s West Virginia locations participate with both exchange plans offered in West Virginia (Highmark West Virginia and CareSource). Additionally, if you are concerned about the cost of your care, you can access more information about our financial assistance program online or reach out to our help line at 304-974-3540.