Medical Billing Rules: What's Legal & What's Not For an Out-Of-Network Provider?


You're going to hear a lot as you start to research this about what's legal and what's not legal when it comes to being an out-of-network provider. And there's been a lot of challenges and a lot of misunderstandings when it comes to whether or not you are responsible for balance billing patients and whether or not patients have to pay co-insurance and deductibles and if it's legal for you as a provider to make your own determination on how you will bill out-of-network patients.

Now, out-of-network patients will generally have a higher deductible or a higher co-insurance as the penalties for going out-of-network. Several providers make a decision to waive that or they charge the patient the same amount that they would have had to pay if they were in network as per Medicare guidelines.

There's a big difference between waiving their co-pay and deductible altogether and still charging the patient the same amount that they would have had to pay if they were still being seen by an in-network provider.

Our expert mentioned it in a recent billing conferencethat one of the arguments that you'll often hear is that Medicare finds it illegal for a provider to waive co-pay and co-insurance that only applies to government plans. So clearly, if you're a Medicare provider, it's against the law to waive Medicare co-insurance and deductible.

But we are talking specifically about those commercial plans in which you've made a decision to become an out-of-network provider. That means that you are no longer bound to the contract that required the co-insurance and the deductible to be billed.

So based on your state, and in most states it is legal for the provider to make a determination on how they will address co-pays and co-insurance for patients who are with a non-contracted payer as per medical billing rules. So when reading that, take care to note that they're talking about contracted payers and they're talking about government payers.

In a lot of situations, some of the commercial payers will use that information in a way that puts it in an accurate light in order to give providers the impression that they're not allowed to make determinations on co-pay and co-insurance and deductible when they're dealing with an out-of-network patient. But in most states, the providers absolutely do have the right to do that as long as they have a fully written policy that is consistent when it comes to that.

So as a provider were to have a policy that stated all patients will be charged in-network co-insurance deductible and co-pay, then that is your written financial policy which is consistent through all patients according to the medical billing guidelines.

And that gives you the freedom to still require that payers pay you a rate that's reasonable for you without passing the burden along to the patients. And that would be one of the key points that you would want to put into the information that you share with patients as you transition to out-of-network because your patient's primary concern will be, “Is this going to fall on me? Now if the payer won't pay, does that mean I'm going to be stuck with a huge bill?”

So it's important to make sure that communication is clear with your staff and with the patients, that they will not be charged for anything other than what they would have paid if they have gone to an in-network provider if your decision is to create a financial policy that states that.

But whatever the decision that is made, it has to be consistent and consistently followed and put into writing to become a part of your policy and your standard operating procedures.

Medical Billing Training Tip: So first step that you would want to take after you started to consider whether or not out-of-network strategy might be best for your facility or your practice would be to review your existing contracts. And there are some keys that you'll want to look at as you go through your contracts in order to determine what you're really receiving as reimbursement.

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