Out-of-Network and What It Means

A physician is out-of-network when a contract has not been established with a health plan.

When providing services to out-of-network patients:

  1. Collect the balance up front, at the time of service. Collecting from patients after they’ve received services is much harder.
  2. Disclose to patients up front if you are out of network with their health plan.
  3. Request a single-case agreement from the health plan. If approved, you will file the claim as if you are in network. The claim will be paid according to the details of the agreement.
  4. Decide if you will file claims on behalf of your out-of-network patients or if you will require them to file their own claim (see options below).
  5. Make sure your policies and procedures are clear and consistently followed.
  6. Calling to check benefits isn’t enough. Check benefits online and get the information in writing. If the patient has out-of-network benefits, you may be required to obtain prior authorization for services provided.
  7. Have a policy on refunds and overpayments. Do not retain credit balances for more than 30 days after discovery.

Keep in mind:

  1. You are entitled to your full fee, even if the patient has out-of-network benefits. You may collect from the patient the difference between what insurance paid and your billed fee.
  2. You are not bound by a contract with a health plan with which a patient has out-of-network benefits.
  3. Even if you accept assignment on a claim, the health plan may still send the check directly to the patient. If you did not collect at the time of service, and you file the claim on behalf of the patient, you may not receive payment from the health plan. You must then spend time and money to collect from the patient.

Options when providing services to out-of-network patients:

  1. File the claim as a courtesy to the patient.

    As noted above, it is still important to collect the full fee upfront. HMOs typically do not pay out-of-network benefits, whereas other plans may. Even with plans that pay, the cost for the patient is still much higher than if the patient stayed in-network.
  1. Provide the patient with a printed claim form (1500) or itemized statement. The patient can file the claim directly to his or her health plan. At the minimum, provide the patient with the following information:
  • Patient name, date of birth, address;
  • Insurance information including patient ID and group number;
  • Physician’s tax ID, NPI, group NPI, address;
  • Date of service;
  • CPT and diagnosis codes; and
  • Amount charged.

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Last Updated On

March 03, 2022

Originally Published On

March 03, 2022