Business & Finance

How Does Out-of-Network Billing Done Correctly?

There are several ways that doctors and other providers can bill out-of-network patients. 

These charges can add up quickly, and you may owe more than your health plan’s copayments, coinsurance, and deductible. When this happens, you can have difficulty knowing what to do next.


Get Accurate Information

Whether you need a specialist or have an emergency, getting accurate information about out-of-network billing is essential. It will lower your financial and reputational risks and assist you in making well-informed decisions regarding your care.

You should anticipate paying more if you get medical attention from a doctor or other provider who isn’t part of your health plan’s network than you would have if they were. In many cases, this extra cost is called “balance billing.”

Most health plans require you to sign a notice and consent form before you receive services from an out-of-network provider or facility. The form lets you know your protections from unexpected medical bills, estimates how much your out-of-network care might cost, and enables you to opt-out.

Balance billing can be a frustrating experience, and it can also damage your credit. So the first thing to do is call your provider and insurance company to try to resolve the situation.

The next step is to compare your EOB with your out-of-network bill. If you get a bill from a doctor that says you owe more than what is on your EOB, ask to have it reviewed by a medical billing advocate. These experts can often help you get the charges corrected or reduced.

Make It Easy To Pay

Getting out-of-network billing done right can mean the difference between being able to pay your bill and having it go to collections or damage your credit. The key is to educate yourself about your insurance plan limitations and payment options, ask questions and be flexible.

Fortunately, there are several ways to make it easy for patients to pay their out-of-network bills. These include limiting surprise billing, estimating costs upfront, and requiring that providers fully disclose their out-of-network status before sending you a balance bill.

In addition, some states have laws regulating surprise or balance billing. These laws generally require providers to notify consumers at least a day in advance and provide them with an estimate of the total charges before sending them a balance bill.

For example, suppose you are in an emergency, and an out-of-network provider tries to send you a balance bill for the care you received that day. In that case, you can ask the provider to stop or at least give you a reasonable estimate of the total costs before they mail you a bill.

Similarly, in-network hospitals can gain monetarily by allowing physicians who bill out of network to work within their facilities. But, again, it is because these specialists may offer transfers, such as waiving staffing fees or ordering more imaging studies, that offset hospital spending.

Communicate With Your Patients

From the physician’s viewpoint, these are the steps to make out-of-network billing works:

One in five people receives a bill that reads “out-of-network.” It’s an unpleasant surprise, making patients feel like they’ve been scammed. Fortunately, there are certain things you can do to prevent this from happening and help your patients feel more comfortable.

First, you need to communicate that you’re out of network. It includes verifying that your patients have the correct insurance and telling them how much their visits will cost.

Second, inform them that you can balance bill them after the insurance company pays its share. This amount is often higher than in-network rates and doesn’t count toward a patient’s deductible or annual out-of-pocket limit.

Third, let your patients know when you’re sending them a balance bill and how to handle it. For instance, if you don’t receive your full payment by a specific date, let your patients know they can call their insurance company to get it reprocessed.

Fourth, don’t tell your patients you’ll waive their fees or offer them forgiveness on their bills. It sets a poor financial precedent and can lead to legal trouble.

Fifth, check your patients’ insurance plans before each appointment. It will ensure that you’re billing the right amount and avoid any surprises down the road.

Finally, be aware of commercial payers’ unique rules about out-of-network claims. These rules vary widely by the insurer and can be complicated and administratively burdensome for patients.

Be Flexible

For a provider, billing out-of-network is a complex and challenging challenge. Not only are you up against a competitive and often challenging market, but commercial payers can be very stingy when paying for out-of-network services.

Providers need to be flexible and adaptable to make the most of out-of-network reimbursement. For instance, they need to be able to respond to patient requests for ad hoc financial reductions, and they must have clear guidelines that they can use to balance ethics with business considerations.

The best approach to accomplish this is to have a specific financial policy that spells out the fundamentals of out-of-network invoicing and compliance requirements. In addition, it will help ensure that patients understand the billing process they’ll be following and avoid confusion from both sides.

Another essential part of the out-of-network billing process is being transparent about pricing. Payers aren’t as willing to foot the bill for out-of-network care as for in-network care, so setting a fair price for your services is essential.

The most successful out-of-network providers use a strong negotiation strategy to maximize reimbursements. It can involve several tactics, from responding to counteroffers to appealing underpayments. Regardless of your volume, taking advantage of these strategies is worth the time. Moreover, they can increase profitability and reduce bad debt.