For most people, their health insurance policy allows them to visit a physician who is designated as an accepted in-network provider. That means that the fees for doctor's services will be covered under the terms of the policy. Most health plans provide the names of doctors who comprise their network. You can choose any of them as your primary health care provider- but what if you want to see a doctor who specializes in a certain field that you need but is not in network? Does your health insurance policy allow for specialist access?

Health Insurance companies have contractual agreements with physicians to provide their services to members of the plan for a regular fee schedule that is predetermined. This is one of the ways that insurance companies can manage their payouts. Your portion of the cost and the company's portion are known before you visit the doctor. If you see a doctor who is out-of-network, you will certainly pay more and sometime the entire fee for the services rendered. There are very few exceptions. Almost all, HMO and PPO plans have lists of accepted providers. Some include specialists and some do not. More generalized specialties that are considered fundamental to regular health care, such as gynecology, dermatology, pediatrics, etc. are usually included.

If you have a specific condition that requires you to see a specialist who is not an in-network provider in your plan, the situation becomes a bit more involved. Because the fees for these specialist's services are significantly higher than those of most primary care physicians, most plans do not include them in their list of providers. Many of these doctors are not willing to accept the fee schedule that the health plans agree to pay as customary for the services in question and therefore do not want to become affiliated with any plans.

There are two basic ways to deal with the situation. The first option is the least costly; get a referral from your primary health care provider in your health plan. This is required by most policies in order for the company to cover the costs of the specialist access. Your primary care provider or you will submit the referral to the insurance company prior to your visit. The company will then send a letter of approval or rejection indicating whether the fees will be covered and to what extent. The alternative is to make a private appointment with the specialist. You will get the benefits of his expertise but because your health insurance policy won't cover the visit, if the doctor agrees to see you, payment will be due in full at the time of the visit.