Non-contracted practitioners can be reimbursed quite well by insurance if certain conditions apply. There are several important things to know prior to performing any service in such cases.
First, it is critical to check if the patient has out-of-network benefits. You need to make sure that the plan allows them to visit a non-participating provider.
Second, even though you may not be participating with an insurance, you would still need to ensure that your credentials are uploaded into a payer's system. An out-of-network insurance may reject your claim if they do not have your information in their records.
Finally, a payment rate may be different from the one you would charge as a participating provider. Out-of-network practitioners tend to put higher rates for their services. As a result, an insurance may not reimburse an entire claim amount, applying an unpaid part to a patient's responsibility. When this is case, healthcare providers may bill patients for the remaining amount, as long as it has been determined that it is not covered by the plan. This is called "balance billing". Balance billing is prohibited for Medicare and Medicaid patients, as well as for emergency services if certain conditions apply.
Assuming that you have already verified eligibility and your participation status, here is what the payment process of your out-of-network claim would look like:
1) The claim is submitted and processed by the plan.
2) If allowed for payment, the insurance will reimburse the claim based on the following:
• Its own out-of-network rate
• An amount negotiated between the healthcare provider and the insurance, in accordance with the charged amount. A third-party negotiator may contact you and interfere.
If it is denied for an absence of out-of-network benefits - you must verify that the patient's plan indeed does not reimburse the services billed by non-contracted providers. If this is the case, you may bill the patient as long as it is not legally prohibited (like in the case described above).
3) The claim is paid.
If the services have been reimbursed in full – you are done with this claim. If there is a specific amount applied on out-of-pocket expenses – balance billing may be performed.
Overall, submitting out-of-network claims is not a rocket science as long as you keep several things in mind.
Stay tuned for more tips on billing & credentialing!
