Navigating Out-of-Network Billing for Nurse Practitioners

Out-of-network billing is never as easy as it seems. Not understanding how to proceed can cost your practice, and your patient money and frustration.

In this podcast and video, we discuss:

  • Definition of out of network: When a provider has not enrolled with an insurance plan to become an in-network provider.
  • As an out-of-network provider, you can charge the patient whatever your normal fee is and file the claim as a non-assigned claim, or give the patient a receipt to file their own insurance claim.
  • There is no advantage to the patient to seeing an out-of-network provider since they may have higher deductibles.
  • Providers may want to take the assignment on the claim, especially for larger claims like surgeries, to avoid the insurance company sending the check to the patient instead of the provider. It’s important to understand exactly what “assignment” means.
  • If you are not credentialed and don’t have a contract with an insurance company, you can still ask the insurance company to assign the check to you instead of to the patient.
  • Providers are allowed to bill whatever they normally bill as an out-of-network provider and can charge patients below the insurance carrier’s rate if they choose.
  • Providers should always know what a patient’s policy says and what they are covered for and for how much.
  • Patients have the right to waive their insurance at any time for any reason on any claim, which means they can withdraw from the medical provider permission to file the claim and be treated as strictly a cash patient for that day’s service.

While not mentioned in this recording, I suggest you do a search for “out-of-network billing law”. Some states may have a law dictating what you can charge. Keep in mind that issues around the “No Surprises Act” may also play a role.

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Share your experiences with out-of-network billing. What’s worked, and what has not worked with your practice?

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