Travel Insurance Direct Billing and PPO Networks Explained

Travel insurance direct billing means the doctor or hospital sends the bill to your insurer instead of asking you to pay the full amount and claim it back. With US visitor medical plans, direct billing usually happens when you use a provider in the plan's PPO network: you show your ID card, pay any copay or deductible, and the provider bills the insurer for the rest. It is common but not assured. WorldTrips says it will remit payment directly to PPO providers for eligible expenses under Atlas plans, while IMG's certificate for Patriot America Plus says paying providers directly is at IMG's discretion. Knowing the difference helps you avoid paying first and waiting weeks for a refund. You can compare visitor insurance plans on Ombrela and check each plan's network before you buy.

Key facts at a glance

• WorldTrips' Atlas description of coverage says that if you are treated by a PPO provider in the United States, it will remit payment for eligible expenses directly to the provider.
• For claims outside the PPO network in the United States, Atlas limits eligible charges to the lesser of 150% of the Medicare rate or the most common charge in the area.
• IMG's Patriot America Plus pays 100% after the deductible in its US PPO network and 90% out of network, with a $500 out of pocket maximum on that coinsurance.
• On Patriot America Plus, an emergency hospital admission must be pre-certified within 48 hours, or eligible expenses can be cut by 50%.
• IMG's certificate states that pre-certification is not a guarantee of payment.
• CMS says the No Surprises Act protects people in employer plans, individual or group health insurance, and certain other plans; short term limited duration plan members are treated as uninsured for good faith estimates.

What does direct billing mean in travel insurance?

There are two ways a visitor medical plan can pay a US provider. With direct billing, sometimes called direct payment, the clinic or hospital submits the claim to the insurer, the insurer pays its share, and you receive a bill only for your part: the deductible, any coinsurance, copays, and anything the plan does not cover. With reimbursement, you pay the provider yourself and then file a claim with receipts to be paid back.

Direct billing matters most for large bills. Paying for a strep test at urgent care and claiming it back is an inconvenience. Paying a hospital deposit for an admission is a different matter. Marketing terms such as "cashless" describe the same idea, but they do not change what the policy wording says, so read the claim settlement clause rather than the brochure headline.

How do PPO networks work in visitor insurance?

A PPO, or preferred provider organization, is a network of doctors, hospitals, and clinics that have agreed to discounted rates with the network. Visitor medical plans usually rent access to an established US network rather than building their own. In the plan data Ombrela receives from carriers, many comprehensive visitor plans use the UnitedHealthcare PPO network, including Patriot America Plus, Atlas America, and the Safe Travels USA plans, while IMG's limited plan Visitors Care uses the First Health PPO network.

A PPO is not a closed system. Atlas's coverage description says nothing restricts your right to choose any hospital or doctor, and IMG's certificate says you are not required to use the network. What changes is how much the plan pays and how the bill is handled. In network, charges are repriced to the negotiated rate and the provider is more likely to bill the insurer directly. Out of network, you may pay more, may have to pay upfront, and are more exposed to balance billing.

How much do visitor plans pay in network vs out of network?

The difference varies by plan. These are the terms stated in the carriers' own documents:

• Patriot America Plus (IMG). In the US PPO network, the plan pays 100% after the deductible. Out of network in the US, it pays 90% with a $500 out of pocket maximum on that coinsurance, so the traveler's share tops out once $5,000 of eligible expenses has been reached. Outside the US, it pays 100% after the deductible.
• Atlas America (WorldTrips). The plan pays 100% of eligible expenses after the deductible, but out of network claims in the US are limited to usual, reasonable and customary charges, defined as the lesser of 150% of Medicare rates or the most common local charge. That cap is where out of network balance bills can arise. Emergency room visits for an illness carry a $200 copay unless you are admitted.
• Safe Travels USA Comprehensive (Trawick). The plan pays 100% after the deductible up to the policy maximum, and Trawick lists the provider network as UHC. Emergency room visits for a sickness without admission carry an additional $200 deductible.
• Safe Travels USA and Safe Travels USA Cost Saver (Trawick). Safe Travels USA pays 90% of the first $2,500 and then 100%; Cost Saver pays 80% of the first $5,000 and then 100%, both after the deductible.
• Limited plans. Visitors Care, VisitorSecure, and Safe Travels Elite pay fixed amounts per service rather than a percentage of the bill, so in network or not, a large hospital bill can leave a big balance. Read fixed benefit vs comprehensive plans.

How do you find in network providers?

Start with the administrator named on your ID card. IMG members can request a PPO directory or search it through the member area at imglobal.com. WorldTrips' provider search for Atlas plans links to UnitedHealthcare's directory for its Options PPO network, and Trawick has a healthcare provider search on its website. Then confirm by phone, because directories can be out of date:

• Ask whether the clinic accepts the specific network printed on your card, not just "UnitedHealthcare", since UnitedHealthcare also runs employer and government plans.
• Ask whether they will bill the insurer directly, and what they expect you to pay at check in.
• For planned care, ask whether the doctors who will treat you, such as anesthesiologists or radiologists, also participate. A hospital in the network does not guarantee every physician there is.
• For minor problems, an in network urgent care clinic is usually faster and less expensive than an emergency room. Our guide on how to see a doctor in the US as a tourist walks through the options.

What is a guarantee of payment for a hospital stay?

Before or soon after an admission, US hospitals typically contact the insurer to verify coverage, and some ask for a written guarantee of payment before accepting a visitor without a deposit. Insurers may confirm eligibility and, for some admissions, issue a written guarantee, but the terms vary by carrier. Ask the insurer's assistance line what it can provide to the hospital.

Pre-certification is related but different. Under Patriot America Plus, inpatient hospitalization, surgery, outpatient surgical procedures, and several other services must be pre-certified; for an emergency admission, pre-certification must be completed within 48 hours or as soon as reasonably possible. If it is not, eligible expenses are reduced by 50% before the deductible and coinsurance apply. Even so, IMG's certificate states that pre-certification is not a guarantee of payment, since claims are still checked against exclusions such as pre-existing conditions. Trawick's Safe Travels plans carry the same 50% reduction for missed pre-certification. Call the number on your card as soon as a family member is admitted.

When do you have to pay first and claim later?

Even on a plan with a network, expect to pay upfront in these situations:

• The provider is outside the network or does not work with travel insurers.
• The provider asks for your deductible, copay, or a deposit at the visit.
• Pharmacies, which often ask you to pay for prescriptions and claim them back.
• Care outside the United States, where the US PPO does not apply.
• The insurer declines to pay the provider directly; IMG's certificate reserves this choice to IMG.

Keep itemized bills, receipts, and discharge summaries, and file promptly. IMG gives 180 days from the date a claim is incurred to submit a complete proof of claim, and Atlas requires proof of claim within 60 days of the last day of the certificate period. Our guide on how to file a visitor insurance claim covers the paperwork, and the top reasons claims are denied shows what to avoid.

How can you avoid balance billing?

Balance billing happens when a provider bills you for the difference between its charge and what your plan paid. Visitors are exposed because out of network claims are paid only up to the plan's allowed amount. To reduce the risk:

• Use in network providers whenever you have a choice, and confirm participation by phone.
• Call the insurer before planned care and for any admission, so pre-certification is in place.
• Do not pay a large bill before the insurer's explanation of benefits arrives, unless the provider requires it; ask the provider to hold the account while the claim is processed.
• Ask for an itemized bill and check it against the explanation of benefits for duplicate or unbundled charges.
• If a balance remains, ask the provider for a self pay discount or a payment plan, and ask nonprofit hospitals about their financial assistance policy.
• Appeal in writing if you think the insurer underpaid, using the timeline in your policy.

Does the No Surprises Act protect visitors with travel medical insurance?

Probably not in the way most people hope. According to CMS, the No Surprises Act's surprise billing protections apply to people enrolled in employer group health plans, individual or group health insurance on or off the Marketplace, the Federal Employees Health Benefits program, and certain government, church, and student plans. For those people, it bans most surprise bills for emergency care and for some out of network care at in network facilities.

Travel medical insurance is not on CMS's list. People on short term limited duration plans are treated as uninsured and get only the good faith estimate and dispute rights described below. Federal rules also list travel insurance as an excepted benefit outside these requirements (45 CFR 148.220), though the federal definition of travel insurance describes policies where health benefits are incidental to other travel cover, which is not how most stand alone visitor medical plans are built. IMG's Patriot America Plus certificate states that it is not subject to the Affordable Care Act. The prudent reading: do not count on the No Surprises Act to block a balance bill while you are on a visitor plan.

One protection is useful. If you are paying a provider yourself rather than having it bill a group or individual health plan, CMS says providers must usually give you a good faith estimate when you schedule care at least three business days ahead or ask for one. If the final bill is at least $400 more than the estimate, you can use the patient provider dispute resolution process, which must be started within 120 calendar days of receiving the bill and has a $25 fee. You can still submit your receipts to the travel insurer for reimbursement.

How to get covered

When you compare plans, look beyond price at the network, the out of network payment rules, and the pre-certification terms. For a visit to a US city with large hospital systems, a comprehensive plan with a US PPO network is usually the practical choice. Get visitor insurance quotes on Ombrela.

Frequently Asked Questions

Does travel insurance pay the hospital directly?

Often, when you use a provider in the plan's network. WorldTrips says Atlas plans pay PPO providers directly for eligible expenses, and many hospitals bill visitor insurers the same way they bill other insurers. It is not assured: IMG's certificate reserves the choice to pay providers directly, and out of network providers may ask you to pay first and claim later.

What is the UnitedHealthcare PPO network on visitor insurance?

It is a US network of doctors, hospitals, and clinics that agree to negotiated rates. Many visitor plans, including Patriot America Plus, Atlas America, and the Safe Travels USA plans, use it for care in the United States. Using a network provider usually lowers the bill and makes direct billing more likely, but you can still see providers outside the network.

Can I see a doctor outside the PPO network?

Yes. Visitor plans with a PPO network do not require you to use it. The plan may pay less or cap eligible charges out of network, though. Atlas limits out of network US charges to the lesser of 150% of Medicare or the common local charge, and Patriot America Plus pays 90% out of network with a $500 cap on your coinsurance.

Is pre-certification the same as a guarantee of payment?

No. Pre-certification confirms that a treatment is medically necessary under the plan's rules. IMG's certificate states it is not a guarantee of payment, because the claim is still reviewed against exclusions such as pre-existing conditions. Missing pre-certification can still cost you: on Patriot America Plus and Safe Travels plans, eligible expenses can be reduced by 50%.

Does the No Surprises Act apply to visitor insurance?

Visitors should not count on it. CMS lists employer plans, individual and group health insurance, and certain other plans as protected, and travel medical insurance is not on that list. If you pay a provider yourself for scheduled care, you can usually ask for a good faith estimate and dispute a bill that is at least $400 higher.

A good network turns a hospital visit into a phone call and a copay instead of a deposit and a refund claim. Compare visitor insurance plans with US PPO networks on Ombrela before you travel.