Check your contract to find out how much more you will pay to go outside the network. This provider makes referrals and decides what care is appropriate for you. The health carrier will not pay for a referral to a specialist unless it has been authorized by the gatekeeper. You should find out whether your plan uses gatekeepers and consider whether you are comfortable with this approach. Perhaps you prefer access to specialty care without a referral.
Health plans compensate physicians in several ways.
Some health plans employ their own physicians to provide treatment to their members. In the past, health carriers typically compensated physicians under a fee for service structure. This meant that a health carrier paid the physician his or her actual charges for a particular service. Under this structure the physician is paid for the actual services the physician provides, but at a discounted rate. The discounted rate is agreed to by the physician and health carrier.