Can still be out of network. When out of network, you can only bill the median in-network rate for all the groups in your region.

Consider these examples (obviously simplified):

- Group A: $150 per 99285 chart
- B: $120
- C: $100
- D: $80
- E: $60

You're out of network. The insurer will reimburse you at $100 since that's the median.

Two years pass, and groups have renegotiated so they can get the easy billing of being in-network.

- A: $150 (no change)
- B: $120 (no change)
- C: $90
- D: $80 (no change)
- E: $60 (no change)

The median rate is now $90, so out of network charges going through arbitration get the median in-network rate. So you get $90.

Now, two more years go by, and insurers have hard-balled those at the top and also those in the median. They care nothing about the lower end of the scale for now. Now it's:

- A: $110 (the insurer says it's more than you get for being out-of-network, and you're still above the mean/average for reimbursements)
- B: $92 (insurer says you're above the new mean now)
- C: they refused an offer of $80 and went out of network; they're no longer used to calculate the median
- D: kept their $80
- E: kept their $60

Now the median is between $80 and $92 ($86), so the out-of-network median rate has now shifted to $86.