Out-of-Network

A healthcare provider who does not have a contract with a particular insurance payer, meaning patients may pay higher out-of-pocket costs and the provider is not bound by negotiated fee schedules.

Out-of-network means you do not have a participating provider contract with a specific payer. You can still see patients who have that insurance, but the financial dynamics are completely different. When you see a patient out-of-network, the patient typically pays a higher share of the cost. Their plan may have a separate, higher deductible for out-of-network services. Their coinsurance might be 40% or 50% instead of the 20% they would pay in-network. And depending on the plan type, some services may not be covered at all when provided by an out-of-network provider. From your perspective as the provider, you can charge your full fee. You are not bound by a fee schedule because you have no contract with the payer. However, the payer will only reimburse the patient (or you, if they pay you directly) based on what they consider the "usual, customary, and reasonable" rate, which is often significantly lower than what you billed. The No Surprises Act, which took effect in 2022, changed the rules for out-of-network billing in emergency situations and for certain non-emergency services at in-network facilities. Under this law, patients cannot be balance billed more than their in-network cost-sharing amount in these situations. The provider and the payer must work out the payment between themselves, either through negotiation or through an independent dispute resolution process. Some providers deliberately stay out-of-network with certain payers because the fee schedules are too low to make participation worthwhile. Others stay out-of-network because the network is closed. Whatever the reason, if you are seeing patients out-of-network, make sure they understand their financial responsibility before the visit. Surprise bills destroy patient trust.