Out-of-network Billing

October 1, 2004

If a patient asks to see me even though I am out-of-network on her plan, can I bill her directly, or do I need to bill the insurance company?

Question: If a patient asks to see me even though I am out-of-network on her plan, can I bill her directly, or do I need to bill the insurance company?

Answer: If you are a participating provider (directly or through an IPA), you are bound by the terms of the payer contract. Often, managed-care contracts dictate that you cannot balance-bill the patient.

If you are not contracted with the payer at all, then you can do as you choose - bill as assigned and accept the allowable or bill the patient.