Billing for in-network rates when I don't participate

June 30, 2011

Question:

Jennifer,

I'm working on the upper east side and I am out of network. I just joined another practice as a part-time employee that has a large in-network following. I want to know how I can bill under the practice and receive in-network rates for those patients.

Thoughts?

Dr. P

Answer:

This is a "have your cake and eat it too question" that comes up all the time. Typically, this question is asked in the reverse - how does my practice bill some in-network and some out-of-network. Here, it sounds like you want all patients for that particular practice to be billed in-network. Now, the answer to this question from my experience (and I welcome others to comment) has been that whether you would be paid in-network rates for services you render and where you are correctly identified as the treating provider when the practice's tax id number is on the HCFA, and the practice does participate, depends on the third party payor. Some payors seem to be paying in-network rates for every claim submitted by a practice is contracted as participating, regardless of whether the provider identifies participates. While other third party payors will actually go by the rendering provider.

Whether or not you are eligible for in v. out of network rates depends on contract; not how a billing form is filled out. Solely by contract. If you are not a contracted provider with an insurer, you are not "in-network" and you would not be eligible for participating in in-network rates. So, to answer the above, the only way I am aware of that you can bill under the practice and receive in-network rates is if you are a participating provider with the applicable third party payors. Of course, many providers take the "wait and see" approach - submit and wait and see. Not preferable.

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