Medical Billing: Health Insurance Networks - dummies

Medical Billing: Health Insurance Networks

Some health care payers and providers participate in networks. You will encounter many networks in billing for medical procedures. A network is essentially a middleman that functions as an agent for commercial payers, like insurance companies. The payers participate in networks who price claims for them.

If a provider is contracted with a network and the insurance carrier is also part of that same network, then the network prices the claim, and the payer (carrier) pays the claim according to the network pricing.

Some carriers participate with several different networks and have the claim priced according to the network that is most advantageous to them. You want to know which networks your patients’ plans access for pricing so that you can avoid unplanned write-offs.

A write-off is the part of the claim that neither the payer nor the patient pays. This particular part of the debt is forgiven. Most contracts define specific payment allowances per procedure. Regardless of the billed amount, the remaining dollar amount is contractually obligated to be written off by the billing provider.

You can find various network symbols on a patient’s insurance card, which represent a pricing network that the payer accesses for pricing claims.