Billing to medical insurance: In-network versus out-of-network


Billing to medical insurance: In-network versus out-of-network #Billing #medical #insurance #Innetwork #outofnetwork Welcome to JibGlobe, here is the new resources we have for you today:


One of the most common questions I hear as an expert in implementation of medical/dental billing into dental practices is: “Do we need to be in-network to bill to medical insurances?” There are multiple things to consider with this question, but the answer depends mainly on the answer to the following question: Which type of medical insurance policies do you want to bill?

Types of insurance

There are multiple types of insurance. The most common are health maintenance organizations (HMO), exclusive provider organizations (EPO), and preferred provider organizations (PPO).

HMO and EPO are similar in that you must be in-network (IN) to bill for these plans, as they do not allow the patient to see any provider that is out of their network (OON). These plans will pay $0 for services you perform if you are out-of-network.

Sometimes—and only sometimes—they will allow the patient to see an OON provider if they are in an emergency situation and need to be seen. An example is a patient in extreme pain due to an abscessed (infected) tooth or some sort of trauma. The HMO/EPO most likely will initially deny services to an out-of-network provider; however, they may pay if you appeal the claim.

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These plans will make you work to get payment, if they agree to pay at all. I advise practices that are OON to avoid billing these types of restricted plans.

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