There is no set and defined payment for out of network providers. Depends on case by case basis and the insurance plans a patient has and what it covers (most of them dont even cover OON benefits) .
What do you mean most don't cover OON benefits?? An HMO maybe but PPO, POS, etc do. OON bases allowables on U&C.
OON providers with high dollar services can send a pre-determination of benefits (CPT Code and provider charge) to the OON carrier to which the carrier will respond that either YES the fee is covered or no it's not.
Not all providers bill to patients btw. They try to get the max from ins and the rest is billed to the patient, provided if any cushion is left.
This is actually fraud unless there is a documented hardship. OON or in network, doesn't matter. Waiving patient out of pocket routinely is fraud.
We gurantee atleast 60% of reimbursements for OON! Thats how we play
Including or not including insurance? That's pretty scary guarantee to make.