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PPO Members Can Avoid High Costs by Using In-Network Providers

Using an out-of-network doctor, hospital, or other health care provider can significantly increase PPO members' out-of-pocket medical costs. That's because when a member sees an out-of-network provider, the member is responsible for the difference between what the provider charges and the amount we pay the provider.

We use an established rate to pay for medical services from out-of-network doctors, hospitals, and other health care providers. However, out-of-network providers' actual charges are often much higher than our established rate, and they may charge members for the difference. This is called balance billing.

When a member sees an in-network provider, they won't receive any additional charges from the provider. Look at the example below.

Example
Cindy injured her knee and required surgery from an orthopedic doctor. Cindy has a PPO plan, which gives her the option to seek services from a doctor in the Blue Cross provider network, or one who does not participate in our network.

The orthopedic doctor Cindy chose charges $90,000 for her surgery. If the doctor is in the Blue Cross network, we would pay a negotiated rate for Cindy's surgery. If the doctor is not in our network, we would pay the established rate for out-of-network surgery.

The chart below shows how Cindy's out-of-pocket costs will be lower if she chooses an in-network doctor.

In-Network Out-of-Network
Provider's Actual Charge $90,000 $90,000
Blue Cross Pays Negotiated Rate Established Rate of $50,000
Balance Bill Amount
(Cindy's out-of-pocket costs1)
$0 $40,000

All dollar amounts in this example and the table are hypothetical and for illustrative purposes only. Out-of-pocket costs do not include deductible, copayment, or co-insurance.

1. Members' actual out-of-pocket costs may be significantly higher than the examples shown, depending on the particular service and the health care provider's actual charge.

  • In many cases, out-of-network doctors, hospitals, and other health care providers charge as much as five times more than what Blue Cross pays in-network providers.
  • Exception: This does not apply to emergency medical care.

How can members find an in-network provider?
Before receiving any services, members can go to www.bluecrossma.com/findadoctor to find an in-network provider, or they can call Member Service at the number on the front of their Blue Cross ID card.

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