An out-of-network patient is a patient whose health plan has no contract with your practice. The plan may still pay part of the bill at its own out-of-network rate, or nothing at all, and the patient usually owes more. Handling these patients well means verifying benefits before the visit, giving clear estimates, following the No Surprises Act, and deciding whether to bill the plan or give the patient a superbill.
This guide walks through each step, with a worked payment example. If you are thinking about joining a network instead, see our credentialing and contracting services.
Out-of-Network Billing at a Glance
| Step | What to do |
| 1. Verify benefits | Check out-of-network deductible, coinsurance and whether the plan (e.g., an HMO) pays out of network at all |
| 2. Check No Surprises Act rules | Emergency care and some care at in-network facilities cannot be balance billed |
| 3. Give an estimate | A Good Faith Estimate is required for uninsured/self-pay patients |
| 4. Decide how to bill | File the claim for the patient, or collect at the visit and give a superbill |
| 5. Collect | Payment at the visit or an agreed payment plan |
| 6. Follow up | Track out-of-network claims and appeals separately |
Formula: Patient owes = out-of-network deductible (if not met) + coinsurance on the allowed amount + balance bill (only where allowed).Worked example (illustrative figures): You charge $300. The plan’s out-of-network allowed amount is $180, the deductible is already met, and coinsurance is 40%. The plan pays $180 × 60% = $108. The patient owes $72 coinsurance. If balance billing is allowed, the patient also owes $300 − $180 = $120, for a total of $192. If the No Surprises Act applies, the patient owes only the in-network cost-sharing amount instead.
Understanding Out of Network Coverage
How Does Out of Network Coverage Work?
When a patient has out of network coverage, their insurance company may still provide some level of coverage for services obtained from non-contracted providers. However, the coverage is often limited, and the patient may be responsible for a more significant portion of the costs.
Pros and Cons of Out of Network Care
Advantages of Seeking Out of Network Care
Access to Specialized Providers: Out of network care may give patients access to specialized doctors or facilities that are not available in their network.
Privacy and Confidentiality: Some patients prefer seeking out of network care to maintain a higher level of privacy and confidentiality.
Disadvantages of Out of Network Care
Higher Costs: Out of network care can be more expensive for patients due to higher out-of-pocket expenses and potential balance billing.
Complex Billing Process: Billing and reimbursement processes for out of network care can be more complicated and time-consuming.
Strategies for Handling Out of Network Patients
Developing Transparent Pricing and Billing Policies
Transparency in pricing and billing is crucial when dealing with out of network patients. Clearly communicating the expected costs of services before treatment can help build trust and prevent surprises for patients.
Negotiating Single-Case Agreements With Payers
When a patient needs care that no in-network provider can offer, ask the payer for a single-case agreement: a written, one-time rate for that patient’s treatment. Get it in writing, with the codes, rate and dates covered, before treatment starts.
Navigating Out of Network Claims
Tips for Submitting Out of Network Claims
Decide first whether you will file the claim or the patient will. If you file, check whether the plan pays the provider or the patient; many plans send out-of-network payments to the patient even with an assignment of benefits. If the patient files, give a superbill with your NPI, tax ID, CPT and ICD-10-CM codes, charges and payment received. Either way, file within the plan’s out-of-network deadline.
Dealing with Claim Denials
Claim denials are not uncommon in out of network situations. Providers should be prepared to appeal denials and provide additional information to support the claim’s validity.
How to Communicate Out of Network Costs to Patients?
Transparent Communication about Out of Network Costs
Openly discussing out of network costs with patients can help manage their expectations and prevent financial surprises. Being upfront about potential out-of-pocket expenses fosters trust and patient satisfaction.
Presenting Alternative In-Network Options
Offering patient’s information about in-network alternatives can provide them with cost-saving options. This allows patients to make informed decisions about their care.
Building Referral Relationships
The Importance of Networking
Building a network of out of network providers can enhance a practice’s capabilities and reputation. Networking enables collaboration and referral opportunities.
Working With In-Network Colleagues
Developing strong relationships with out of network doctors fosters cooperation and a positive patient experience. Collaborative efforts lead to better patient outcomes.
Managing Out of Network Patient Expectations
Setting Clear Expectations
Setting clear expectations about billing practices, coverage, and treatment plans is essential to avoid misunderstandings and ensure patient satisfaction.
Addressing Common Patient Concerns
Addressing common concerns such as cost, insurance coverage, and payment options helps patients feel more at ease and confident in their decision to seek out of network care.
Overcoming Out-of-Network Challenges
Out of Network Reimbursement Rates
Navigating out of network reimbursement rates can be challenging. Providers should strive to negotiate fair rates and explore other revenue streams to offset potential losses.
Handling Out of Network Patient Complaints
Addressing patient complaints promptly and professionally is vital for maintaining a positive reputation. Resolving issues promptly can also prevent negative online reviews.
Strategies for Improving Out of Network Patient Retention
Implementing patient retention strategies, such as personalized care plans and exceptional customer service, can encourage out of network patients to continue seeking care at your facility.
Ensuring Compliance and Legal Considerations
Out of Network Laws and Regulations
State laws on balance billing and out-of-network payment vary, so check your state’s rules as well as the federal ones. For Medicare patients, a non-participating provider who does not accept assignment can charge no more than the limiting charge, 115% of the non-participating fee schedule amount.
The Impact of Surprise Billing Laws
The federal No Surprises Act, in effect since January 1, 2022, bans balance billing for emergency services, for non-emergency services from out-of-network providers at in-network hospitals and ambulatory surgical centers (unless valid notice and consent is obtained where allowed), and for air ambulance services. In those cases the patient pays only in-network cost-sharing, and payment disputes between provider and plan go to open negotiation and then federal independent dispute resolution. Uninsured and self-pay patients must also receive a Good Faith Estimate for scheduled care.
Leveraging Technology for Out of Network Management
Utilizing Digital Platforms for Communication
Using digital platforms for communication can streamline patient-provider interactions and improve the overall patient experience.
Out of Network Patient Portals
Implementing patient portals can enhance communication and empower patients to access their medical information easily.
Measuring Success with Out of Network Patients
Key Performance Indicators for Out of Network Care
Establishing key performance indicators (KPIs) allows providers to assess the success of their out of network patient strategies and identify areas for improvement.
Analyzing Out of Network Patient Data
Analyzing patient data can provide valuable insights into patient preferences, needs, and satisfaction levels, enabling providers to tailor their services accordingly.
Marketing Your Out-of-Network Services
Out of Network Patient Acquisition Strategies
Effective marketing strategies can attract new out of network patients and increase the visibility of your services.
Highlighting Unique Selling Points
Showcasing your practice’s unique strengths and advantages can set you apart from competitors and attract more out of network patients.
The Future of Out of Network Patient Care
Out of Network Healthcare Trends
Staying informed about emerging healthcare trends can help providers anticipate changes and adapt their strategies accordingly.
Innovations in Out of Network Healthcare
Embracing technological and healthcare innovations can enhance the quality and efficiency of out of network patient care.
Frequently Asked Questions
How do I know if a patient is out of network?
Patients may inform you that they have out of network coverage, but it’s essential to verify their insurance information beforehand.
Can out of network providers balance bill patients?
Only where the law allows it. The No Surprises Act bans balance billing for emergency care, most care from out-of-network providers at in-network hospitals and surgery centers, and air ambulance services. Many states have their own limits too. Outside those protections, the patient may owe the difference between your charge and the plan’s allowed amount.
Is out of network care more expensive for patients?
Yes, out of network care is often more expensive for patients due to higher out-of-pocket costs.
How can I negotiate with out of network providers?
Contact the plan’s provider relations or case management team, explain why no in-network provider can give the care, propose a rate with supporting data, and get the agreement in writing before treatment.
What is the process for submitting out of network claims?
To submit out of network claims, gather all necessary documentation, code the services accurately, and submit them to the insurance company.
Can patients appeal out of network claim denials?
Yes, patients can appeal claim denials by providing additional information to support the claim’s validity.
Are there any alternatives to out of network care for patients?
In-network care and seeking providers who participate in the patient’s insurance network are alternatives to out of network care.
How do I build a network of out of network providers?
Networking events, professional organizations, and online platforms can help you connect with out of network providers.
How can I improve patient satisfaction with out of network care?
Transparent communication, personalized care, and addressing patient concerns can contribute to improved patient satisfaction.
What legal issues should I be aware of when handling out of network patients?
Providers should be aware of out of network laws and regulations, as well as surprise billing laws, to remain compliant and avoid legal issues.
Can an out-of-network provider balance bill a patient?
Sometimes. The No Surprises Act bans balance billing for emergency care, for non-emergency care from out-of-network providers at in-network hospitals and surgery centers (unless valid notice and consent is given where allowed), and for air ambulance services. Outside those situations, balance billing depends on state law and the patient’s plan.
What is a Good Faith Estimate?
Under the No Surprises Act, providers must give uninsured or self-pay patients a written estimate of expected charges for scheduled care. If the final bill is at least $400 more than the estimate, the patient can use the federal patient-provider dispute resolution process.
How are out-of-network claims paid?
The plan pays based on its out-of-network allowed amount, not the provider’s full charge. The patient then owes the out-of-network deductible and coinsurance, and, where balance billing is allowed, the difference between the charge and the allowed amount.
What is a single-case agreement?
A single-case agreement is a one-time contract between an out-of-network provider and a payer to treat a specific patient at an agreed rate, often when no in-network provider can offer the needed care. It should be in writing before treatment starts.
Bottom Line
Out-of-network patients can be a sound part of a practice, as long as benefits are verified first, estimates are clear, No Surprises Act protections are followed and collection is agreed before the visit. The payment example is illustrative; federal rules are summarized here and state laws vary. For help with estimates, patient payment policies and out-of-network claims, see Zmed Solutions’ revenue cycle management services. Patients with disputed bills may also work with a medical billing advocate.
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