Healthcare providers who start a private practice have the option to apply for in-network status with insurance carriers or remain as an out-of-network provider.
Out-of-Network Coverage
A provider can elect to provide a super bill to their patients, in order for their patients to directly submit a claim to their insurance for out-of-network coverage. The insurance carrier will then cover whatever their out-of-network rate is for the particular service. However, for all out-of-network services, the patient is always responsible for the full amount charged by the provider. It is up to the provider if they will accept, as partial payment the insurance coverage or not.
In-Network Coverage
Alternatively, many practitioners will become in-network with various insurance carriers. By doing so, the provider agrees to accept whatever the company’s contracted rate is for a given procedure. Providers should be advised that contracted status follows practitioners wherever they go. As a result, if a practitioner wants to become out-of-network who was once in-network, they will need to disenroll with the particular carrier directly to ensure that no future issues will exist.
The disenrollment process for commercial insurers generally takes about 60 to 90 days. The practitioner must follow the specific instructions from each individual carrier in order to withdraw from their system — and this process must be officially complete in order to be considered an out-of-network provider.
Medicare Coverage
Medicare offers physicians a two year opt-out and during that time period, practitioners cannot see Medicare patients nor submit any claims. It is important to note that certain specialists are not allowed to opt-out of medicare and before accepting or not accepting Medicare patients, one should be fully aware of their status with Medicare and what they are allowed or not allowed to do at any given time.
For practitioners who are considering starting their own practice, it is important to understand the rules and parameters of insurance carriers in order to determine what type of network status to pursue.
Stephanie J. Rodin, Esq.
Rodin Legal, P.C.
Email: info@rodinlegal.com
Tel: (917) 345-8972
Fax: (917) 591-4428
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