Being an In-network Doctor versus Out-of-Network


Insurance is getting riduculous.  Our “sick contracts” offer few protections for patients and fewer for doctors.  Higher premiums and fewer benefits for all.  Is it even worth being in-network with an insurer?

There are two primary benefits to being in-network.  The Insurance company will refer patients to you and the patient will be responsible for less money.

Is there an advantage to being out-of-network?  Yes, you can balance bill the patient for the amount their insurance didn’t cover, which is likely everything.

Let’s take a closer look at two situations . . .

In-Network Provider

Most patients will try to seek out an in-network provider.  You will show up on their list and generally the patient will only be responsible for a copay after thier deductible, which could be very high.

Are you in network with my insurance doctor?

Photo used under Creative Commons from futureshape

As an in network doctor, you must write off the difference between your actual charge and what the insurance company says you can charge that patient.  YOU MAY NOT BALANCE BILL THE PATIENT.

The current problem in my office is that patient copays have in some cases risen to amounts that are more than our charge for a visit.  Basically, this means that the patient pays for the visit themselves with no help from their insurance.

This of course leads to whining from the patient and the doctor is stuck in the middle again.

Out-of-Network Provider

Many patients will hear how great you are from other patients and want to come to you.  They will be suprised that you aren’t in network with XYZ insurance company.

Whatever your reason for being out of network you have two options, you can bill them the full cost of your care according to your fee schedule or you can submit to their insurance to see if it will cover anything.

Unless the insurance is amazing, it will likely have poor benefits.  There are a few companies that have great benefits even for out of network, but the patient will likely still be responsible for a deductible, coinsurance, or a copay.

Since you are out of network, you can bill the patient for the remaining balance due up to your fee schedule.

Many doctors from on balance billing the patient, but it is a decision that is up to the doctor.  Whatever the decision, It should be applied fairly across all patients.

Conclusion

There are probably a few health plans in your area that would be worth being on because they are good or great plans that pay well or because you will get many referred patients by being on a provider on the plan.

As a young practice, it would likely be prudent to sign up for as many insurance companies as will let you in so that you can start seeing referred patients.  This is the case even if there are strict stipulations requiring pre-approval, etc.  You can always leave the group after you are well established with the better insurance companies.

What has been your worst experience with an insurance company?

Leave a Reply