In-network Vs Out-of-network ? A Detailed Understanding

Posted by Ecareindia on October 31st, 2014

Understanding a health insurance provider network and its types is very important, as it not only impacts the costs of the healthcare services provided, but also the Provider reimbursements. Providers and Healthcare Facilities are categorized into in-network and out-of-network. They may be contracted either with an HMO or PPO. When patients get their care from in-network Providers, their co-pays and coinsurances will be lesser. The same will be higher, if patients choose to get their care from out-of-network Providers. The medical claims processing at the Provider’s or the outsourcing medical billing company’s office also gets impacted due to this variation. Therefore, understanding the differences between these two networks is highly essential for patients, Providers, and medical billing companies.

In-network Provider:

· Providers who are contracted with patients’ insurance network are called as in-network providers. Patients visiting in-network Providers will get quality healthcare services at discounted prices.

· Co-pays and coinsurances are lesser with in-network providers.

· Patients’ healthcare plans are directly billed, if they opt for in-network providers.

· The insurance plan pays the maximum percentage of the billed amount reducing patients’ out-of-pocket costs.

In-network Medical Billing: The medical claims processing services associated with in-network providers is easier than billing out-of-network claims. In addition, patients will not be charged what is called a ‘Balance Billing’ that is usually charged for patients who are out of network.

Out-of-network Providers:

· Providers who are not contracted with patients’ insurance network are called out-of-network providers.

· Most people do not choose out-of-network providers unless and otherwise there is an emergency.

· Co-pays, coinsurances and deductibles will be higher with out-of-network providers.

· Patients will be expected to pay the full cost for the services provided as some health plans like HMOs do not reimburse Providers who are out of network.

· Some health plans like PPO may provide coverage to out-of-network providers but in those cases, patients’ out-of-pocket costs would be higher.

Out-of-network Medical Billing: The medical claims processing services associated with out-of-network providers is quite complicated. Out-of-network providers will bill patients what is called a ‘Balance Billing.’ It is the difference between the Providers’ billed amount and the Payer’s reimbursement to the out-of-network provider.

One of the major issues faced by Providers and outsourcing medical billing companies who are out of network is that the rate of denied claims increases. Another main disadvantage is that many Payers do not accept AOBs or Assignment of Benefits between patients and Providers.

Outsourcing medical billing companies will find out-of-network medical claims processing easier if they choose to offshore medical billing.

About e-care India:

e-care India has 14 years of experience in the industry. e-care’s 3 offshore medical billing delivery centers have been providing end-to-end medical claims processing services seamlessly to its clients. To know more about e-care and its services, log on to


About the Author

Joined: June 20th, 2011
Articles Posted: 88

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