In-Network Doctor vs Private Doctor: The Difference, What You Pay, and How Reimbursement Works

When you need a specialist through your private insurance, there are usually two routes: an in-network doctor (רופא בהסדר) — you pay a fixed copay and the insurance company settles the balance with the doctor directly, or a private doctor outside the network — you pay the full fee and submit a reimbursement claim. The difference between the routes can reach hundreds of shekels per visit. In this article we'll walk through the full journey: from "I need a dermatologist in Haifa" to a covered visit — including what to do when the doctor you wanted isn't on the list.

What an "in-network doctor" is and why it matters

An in-network doctor (also called a "contracted doctor") is a doctor who has signed an agreement with your insurance company. The agreement sets the rate in advance, so you pay only a fixed copay (השתתפות עצמית) — directly to the doctor — and the insurance company settles the balance with them. No receipts to keep, no claim to file, and no price surprises.

A private doctor outside the network works with you alone: you pay the full fee, and if your policy has the relevant coverage — you submit a reimbursement claim and get part of the amount back, according to the policy's terms and caps. Important to know: "in-network" is always relative to a specific company and a specific service. A doctor can be in-network with Harel but not with Phoenix, and in-network for a consultation but not for another procedure.

From search to visit: the in-network route, step by step

1. Confirm what you have. Which company insures you, which plan, and whether you have coverage for a specialist consultation. If you don't have the documents at hand — here's how to get your full policy documents.
2. Find a doctor. Each of the large insurers has a doctor locator on its website: filter by specialty and city and you'll get the relevant list of in-network doctors. Make sure to search in the locator of the company that insures you — the lists differ between companies.
3. Check that the coverage applies. Most policies have an annual quota of consultations, and sometimes additional conditions. A visit to an in-network doctor usually counts within that quota.
4. Book an appointment and pay the copay. You book through the company's call center or directly with the doctor, and pay the copay to the doctor at the visit itself.

How much you pay with an in-network doctor

With an in-network doctor you usually pay a fixed copay on the order of about 150 to 160 NIS per consultation, directly to the doctor. Note: this copay usually cannot be claimed back — it's the part that stays with you. An online consultation with a specialist, at companies that offer one, is usually cheaper. The exact amount is written in your policy, and we explained in depth how copays work and where to find them in your policy.

A private doctor outside the network: how the reimbursement route works

Chose a specific doctor who isn't on the network list? In most policies that's not the end of the road — you switch to the reimbursement route:

• Pay and keep documents. Pay the doctor the full fee and keep original receipts, and — if the company requires it — the referral and the visit summary too.
• Submit a reimbursement claim. On the insurance company's website or app, with the documents attached. The insurance company checks entitlement under the policy's terms and usually responds within 30 days of receiving all the documents.
• Receive a partial reimbursement. The reimbursement is usually limited by a cap per consultation — in different policies this means hundreds of shekels and sometimes more, per the policy — and by an annual quota of consultations. The difference between what you paid and the reimbursement stays with you.

These numbers vary a lot between policies and between plans, so before booking an expensive private doctor it's worth checking your policy for the reimbursement cap per consultation and the number of consultations you have left this year.

The doctor left the network list? It happens

Network lists are not fixed — doctors join and leave from time to time, and the insurance companies note that the list may change. A doctor who was in-network at your last visit isn't necessarily in-network today. So:

• Close to booking, check the doctor in the up-to-date locator on the company's website.
• If in doubt — call the service center and ask for confirmation that the doctor is in-network for the service you need.
• If the doctor has left the network, choose: another in-network doctor at a fixed copay, or stay with them and switch to the reimbursement route, with everything that entails.

So which route should you choose?

There's no single right answer. The in-network route is cheaper and simpler: a price known in advance, no paperwork. The reimbursement route is worth considering when a specific doctor matters to you — say, a specialist who knows your case — and you're willing to pay the difference above the reimbursement cap. The decision depends on your policy's numbers: the in-network copay, the out-of-network reimbursement cap, and the annual quota.

How Ravit can help

The answers relevant to you are in the policy itself. Send Ravit your policy documents on WhatsApp, ask in plain language, and get an answer based on your policy with a reference to the relevant clause — and when there’s no certainty, Ravit says so honestly instead of guessing.

The information in this article is general only and does not constitute medical, insurance, legal, or pension advice, and is not a substitute for reading your policy terms or consulting a licensed professional. Coverage, amounts, and conditions vary between policies and change over time — always verify against your own specific policy and an authorized professional.