Get paid for your services: In-network vs. out-of-network billing

By Dava Stewart

Insurance is confusing. There are so many variables and so much jargon that it can be difficult to know exactly what you can and cannot expect. There’s Medicare, from which chiropractors do not have the choice of “opting out,” then there are private insurance companies, where DCs can choose to be in-network or out-of-network. The difference is in how you bill and from whom you are paid.

One thing that may confuse potential patients is that being “out-of-network” does not mean that they are prohibited from seeing you. Many insurance companies require their customers to pay a higher co-insurance or meet a different deductible for out-of-network providers. And, of course, patients always have the option to pay out of pocket to see the provider they want to see.

Another area of confusion for patients could be that they think they will have to pay in full to see an out-of-network provider. The majority of insurance policies will provide a partial reimbursement for patients who choose an out-of-network provider. This means that the patient pays the provider the full amount for the visit, then the insurance company sends the reimbursement directly to the patient later.

When a DC is in-network, the situation can be more complicated. The insurance company requires an annual contract, and DCs should read those contracts very carefully. They will include stipulations such as the time frame during which claims must be submitted, whether you must accept reduced fees in certain situations, and many other points that could well impact the bottom line of your practice.

As far as billing, when you are in-network, the patient pays their co-insurance or deductible in your office, then you submit the claim for the remainder of your fee. The biggest advantage, of course, is that you are listed in the insurance company’s list of in-network providers. Most patients are going to look there first when they need care.

You can choose on a company-by-company basis whether or not you want to be in-network or out-of-network. You may also choose to operate a “cash-based practice,” although it’s important to remember that you will still have to choose how you will be classified regarding Medicare. You are also not locked-in forever in how you choose to operate your practice, but there are some obstacles and pitfalls to be wary of when you choose to drop an insurance company or to switch to being a cash-based practice.