An out-of-network  or non participating provider is a healthcare professional which has not contracted with the patient’s insurance company for payment of the medical bills/claims at a negotiated rate.

Some health plans, like HMOs and EPOs, generally do not pay out-of-network providers at all (except in Er and life threatening situations), which means that the patient would be responsible for the full or partial non-covered amount charged by the healthcare provider if they’re not in the patient or insurer’s network. Other insurance plans provide coverage for out-of-network providers, but the patients out-of-pocket costs would be higher than it would be if you were seeing an in-network provider.

For example:

Out-of-network providers do not have any contract or agreement with the patient’s insurance company (in most cases, they’ll be in-network with other insurance plans, even though they’re out-of-network with your insurance). So if they bill $160, they’ll expect to collect the full $160. Your insurance plan might pay part of the bill if the plan includes out-of-network coverage. But the patient will be responsible for whatever isn’t covered by your insurance which will be the full amount if your plan only covers in-network care.