In-network health care providers like hospitals and physician care centers have a specific agreement with particular insurance agreeing to offer medical care at a discounted rate, for patients covered by that specific payer. The agreement makes reimbursements, and other processes seamless for the providers. “Out-of-network” providers do not sign any specific agreement with your insurance, leading to a more complex reimbursement process, many times with self-pay elements.
What makes In-Network a popular choice?
Many medical care providers are continually evaluating whether or not to become a part of in-network services offered by the payers. All the hospitals, doctors, specialists, and pharmacies that join the insurance in-network services agree to provide services and care to patients at a discounted rate.
While this does lower the reimbursement rate but ensures a repayment. Unlike the situation in out-of-network billing, patients of the in-network practitioners do not have to shell out any extra fee charges from their pockets other than those fixed in their insurance plans. Hence, many times prefer to visit physicians or specialists who are a part of in-network. The insurance makes the reimbursement to the in-network practitioners in a simpler and faster way.
The reimbursement rates of the out-of-network care providers are higher in comparison to those of in-network but the patients find it inconvenient to pay balance charges by themselves after having already invested a considerable amount in their medical insurance plans. This deters them from opting for an out-of-network facility. Therefore despite the rates being higher the overall volume of the reimbursements to the out-of-network doctors decreases significantly.
On the behest of several patients portraying this practice of balance billing as having grave concern to them, the government has been urged to institute laws that restrict the out-of-network care providers to charge any fee over and above the rates fixed for in-network services.
For instance, if an out-of-network doctor charges $500 for a given service and the in-network rate fixed by the payer for this particular service is around $350, then he will only receive a reimbursement of $350 and will not be allowed to charge the balance $150 from the patient too. This has created a financial strain on those out-of-network practitioners offering great services but is not being repaid at par.
This has led several out-of-network care providers to move in-network. They find this as a more reliable and uncomplicated way to receive reimbursements.
While it is debatable that this process completely safeguards the interest of the patients and out-of-network care providers, this is being acknowledged and adopted by several practitioners.
If you are a medical practitioner falling under the out-of-network group, you may want to re-evaluate your preference to be a part of in-network services. You may assess the key parameters such as quality of service, patient turn-out for the services you offer, and volumes of reimbursement expected from both the models and take a wise decision of moving in-network or staying out-of-network. A professional medical billing services firm can help you make a data-backed choice.
Atlantic RCM is one of the leading multi-specialty medical billing companies in USA that serves 25+ major medical billing specialties. Our experts work across your practice in billing, collections and account receivables management, to help you succeed.
Get in touch with the leading medical billing outsourcing company to learn more. Call us at (786) 264-1222 or write to us Info@atlanticrcm.com