Understanding an Out-of-Network Exception in Medical Billing

Whether you are a patient, medical practitioner or a healthcare provider, understanding an out-of-network exception in medical billing can be an important part of your healthcare experience. An out-of-network exception is when a patient seeks medical services that are typically not covered by their health insurance network. The out-of-network exception makes it possible for the patient to receive those services and still have them covered, at least to some degree, by their health insurance.

What is an Out-of-Network Exception?

In essence, an out-of-network exception is when a patient pays for a healthcare service or treatment that is not included in their insurance’s network of providers, and the insurance company agrees to pay for part or all of the service. The usual out-of-network exception arrangement will see the patient paying the full, out-of-network rate for the service, and then the insurance company paying a smaller, pre-negotiated amount.

Why Would a Patient Seek an Out-of-Network Exception?

In many cases, a patient may not be able to find a provider for the healthcare service they need, or the nearest provider may only offer the service out-of-network. Another common occurrence is when a patient opts for a specialist or higher-level care that is only offered out-of-network. Patients will seek out-of-network exceptions in order to maintain access to these services that are not available within their health insurance network.

Negotiating an Out-of-Network Exception

Negotiating an out-of-network exception, or agreement, requires the patient to contact the health insurance provider to see if they will agree to pay for the service, either in full or in part, even though it is outside of their network. There are also providers who will try to negotiate for the patient and if an agreement is made, the provider will bill the insurance company directly and waive any remaining balance owed by the patient.

Conclusion

Out-of-network exceptions in medical billing can provide patients with access to healthcare services that are not covered by their insurance network. Understanding an out-of-network exception, and how to negotiate one, is an important part of staying informed about your healthcare coverage and options.