The health insurance and medical billing landscape is constantly changing and full of complexities that often require a team dedicated exclusively to staying abreast of new regulations and submission requirements on an ongoing basis. In the age of Obamacare (The Affordable Care Act, ACA) and an increasingly aging population more reliant on Medicare and Medicaid/Medi-Cal than ever, the way Americans pay for healthcare coverage and medications is constantly changing.
Whether buying coverage through an employer provided private plan, or through an ACA mandated exchange such as Covered California, one thing remains constant. Patients still prefer to maintain as much control over their healthcare choices as possible by choosing their own doctors and having a say in how their healthcare dollars are spent.
Increased choice through flexibility of provider access, and value added through services such as transparent billing practices, are some of the factors that can lead many patients to seek the services of an out of network healthcare provider. If you are looking for more insight into out of network billing, conversion to Concierge or Direct Primary Care call Nexsys at 800-529-3962 or fill out our online contact form.
DIRECT PRIMARY CARE (DPC) & INTEGRATIVE MEDICINE
WHAT IS THE DIFFERENCE BETWEEN OUT OF NETWORK AND IN NETWORK BILLING?
As with any contract, it is important for both the insured and the healthcare provider to understand what services and procedures are covered under the plan before any services are provided and fees are incurred. With in network coverage, the insurance company and medical providers have agreed to a set schedule of fees and prices for services ahead of time.
The insurance company agrees to cover a percentage of the established billable fees under the agreement, with the patient agreeing to cover a specific percentage of the remaining balance in the form of co-pays or deductibles. A “network” of healthcare providers for the purposes of medical billing contracts is very broad and includes a range of healthcare providers in every state. The typical services billed for include:
- RADIOLOGY FACILITIES AND SERVICES
The providers contracted within a network have agreed to what their services will cost and what percentage of each service and procedure each party is responsible for, so patients can get a sense of what they will have to pay before submitting to an exam or procedure.
In network coverage can be straightforward for standard care and routine medical visits. However in cases of emergency hospital services or treatment for serious and complicated illnesses, a patient will most likely be treated by a team of medical professionals, some of which may be In-Network and some of which may not. Therefore, even if a plan includes hospital visits and services, some of the medical professionals working in that hospital and on a patient may not be included in a particular plan’s network and therefore not subject to the plan’s set fee schedule.
OUT OF NETWORK
Depending on the individual plan and insurance provider, many patients are free to see a doctor or use a pharmacy of their choosing if they are Out of Network (OON). Out of Network providers have not agreed to a set fee schedule with insurance companies and are therefore free to charge for their services individually. Depending on the plan, the insurance company may agree to pay for a smaller percentage of the services, with the patient responsible for covering the rest.
WHAT TO KNOW ABOUT CHOOSING AN OUT OF NETWORK MEDICAL PROVIDER
While there are many considerations to take into account when choosing the services of an out of network healthcare provider, there can also be certain advantages for patients that understand their financial obligations and plan accordingly.
The freedom to choose a doctor one feels comfortable with, or to see a specialist if necessary without the fear of insurance company rules and red tape, and a more simplified process is the most common reason many people choose an out of network doctor. For healthcare providers, there can also be significant savings in terms of time, fees billed, and resources invested in working with insurance companies.
HOW CAN NEXSYS HELP OUT OF NETWORK HEALTHCARE PROVIDERS?
The cost of even routine care can be prohibitive for many patients, whether they have full insurance coverage or not. Nexsys offers solutions to help both medical practitioners and their patients receive the medical care and services they need most and can help find payers to help pay for these non-covered fees. Some of the many medical billing services we offer include:
- COURTESY BILLING AND HELP SETTING UP PAYMENT PLANS
- TRANSPARENT BILLING PRACTICES TO HELP SIMPLIFY AND STREAMLINE THE BILLING PROCESS
- CONCIERGE MEDICAL BILLING DESIGNED TO ADDRESS EACH CLIENT’S SPECIFIC PRACTICE NEEDS AND SPECIFICATIONS
CONTACT NEXSYS MEDICAL BILLING TODAY TO LEARN MORE ABOUT HOW WE CAN INCREASE YOUR PRACTICE’S PROFITS AND EFFICIENCY!
We have more than 25 years of experience maximizing profits and reducing administrative and overhead costs for our medical clients across all medical specialties. We offer medical billing and practice management solutions across the country, with dedicated account executives working on individual solutions for each client to increase revenue by as much as 10% – 20%.
Call 800-529-3962 ext. 203 today to learn more, or contact us online for more information. In addition, our user-friendly profit calculator can help you estimate how much additional revenue your Private Medicine practice stands to gain on a monthly or annual basis through our services!