Which Insurances Should My Practice Be In Network With?
By Cristian Popescu, Founder of HealthFlow Billing
One of the most expensive decisions an outpatient practice makes is which insurance networks to join. Sign the wrong contracts and you lock in below-market rates for years. Skip the right ones and you turn away patients every week. Here is how to actually think about it.
Start with three questions for every payer
1. What do they actually pay? Not the contract language, the real allowed amounts per CPT code you bill most. Compare every payer against Medicare as your baseline. A commercial contract paying at or below Medicare rates is a bad contract in almost every market.
2. How many of their members are in your area? A generous fee schedule means nothing if the payer has no members near you. Check employer concentration: what plans do the biggest employers near your practice offer their workers?
3. What is the administrative burden? Some payers require authorization for nearly everything, delegate to third-party networks with their own paperwork, or cap daily reimbursement no matter how much care you deliver. A slightly lower rate with clean claims processing often nets more than a higher rate buried in denials and paperwork.
The payers most outpatient practices should evaluate first
| Payer Type | Why It Matters |
|---|---|
| Medicare Part B | The foundation. Stable rates, predictable rules, and the baseline every other contract gets compared against. Essential for most outpatient practices. |
| The dominant regional Blue plan | Blue Cross and Blue Shield plans usually hold the largest commercial membership in any region. Often the highest-volume commercial contract you will have. |
| Major national PPOs | UnitedHealthcare, Aetna, Cigna. Evaluate each on its actual fee schedule in your area, not its brand name. Some pay well in one region and poorly in another. |
| Workers Compensation | In many states (including California), WC pays above Medicare on a statutory fee schedule with no network contract required. Often the highest per-visit reimbursement available to rehab practices. |
| Local HMO / managed care plans | Volume can be high, but rates and authorization requirements vary enormously. Evaluate carefully. |
When staying out of network is the right call
Being in network is not automatically good. If a payer's rates are far below market, their members can still see you out of network, pay your rate, and submit for reimbursement themselves. You keep your full fee, skip the authorization paperwork, and avoid daily caps. The tradeoff is lower patient volume from that plan. For practices in areas with limited competition, out of network is often the more profitable position with certain payers.
Already contracted? Your rates are probably stale.
Most practices sign payer contracts once and never touch them again. Payer contracts are not set in stone. If your rates have not been reviewed in more than two years, you are likely being paid below what the payer would agree to if asked. A structured rate review, backed by your volume and market data, is one of the highest-return activities a practice can do.
The bottom line
Do not sign network contracts on brand names. Sign them on numbers: the real allowed amounts for the codes you actually bill, the volume the plan brings you, and the administrative cost of getting paid. And revisit every contract at least every two years.
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