Author Topic: In network or out of network?  (Read 3698 times)

tk

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In network or out of network?
« on: April 24, 2009, 12:06:49 PM »
Hello, I am a Chiropractor's office in California and was wondering if it's better to be in or out of network with insurance companies esp. Blue Cross as far as reimbursements. TIA

Michele

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Re: In network or out of network?
« Reply #1 on: April 24, 2009, 12:19:30 PM »
There is no right or wrong answer for participating.  You need to take many things into consideration and make the decision that best fits your office.  For example, is it an area where patients can afford to go out of network, what is the reimbursement rates for the carriers, do they pay out of network to the patient, etc.

Once you have all the info, evaluate it to see what would be best for your office.

Good luck
Michele
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tk

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Re: In network or out of network?
« Reply #2 on: April 24, 2009, 02:11:59 PM »
So generally reimbursement for out of network is higher than for in network patients, right?

PMRNC

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Re: In network or out of network?
« Reply #3 on: April 24, 2009, 05:45:09 PM »
Not always! there are plans out there that will negotiate higher fee schedules but you have to be the one to initiate it, so when you first par with them ,your fee will be their standard In network fee based on schedule but also taking into account location, services, averages.. etc.
Get a good consultant to do the credentialing leg work for you, it's worth the extra money to have it done the right way plus they can help you and your attorney go over the contracts. Carriers will try and sneak things through contracts. Also keep in Mind BCBS has a pretty long wait to get out of network if you ever want to get out.

Linda Walker
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Pay_My_Claims

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Re: In network or out of network?
« Reply #4 on: April 24, 2009, 06:16:43 PM »
The thing about being non par is you can balance bill the patient. It is far cheaper for a client to go in network as opposed to out. So you think hey I can make more being non par...well not really. Lets say you bill 100 and the ins company says the allowable is 60. In net the patient is covered at 90% and you receive 54.00 patient owes 6.00 Out of network, the allowable is still 60, and they cvg is 50%. They will pay you 30 but now the patient is responsible for 70.00 Why 70....because 30 would be his coinsurance, and the other 40 is patient responsibility because you can balance bill the patient. Unfortunately most providers don't collect up front, so now you are trying to collect that money, and have only received a portion of what you could have gotten as in net provider Also some payors (BCBS) will send payment directly to the patient, and you have to follow the EOB. We don't get notice that payment was made to them, we have to contantly check online. Also in addtion to what Linda said, about getting out of network with them (didn't know that) its hell getting in when it comes to DME. BCBS of NC has closed its panel!!

Michele

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Re: In network or out of network?
« Reply #5 on: April 24, 2009, 08:23:28 PM »
The reimbursement for out of network is not usually higher, it is the amount that you can bill the patient that is higher.  Most patients want to go where their cost will be lower, not higher.  And as Charlene said, you then have the job of collecting from the patient.  There are a few companies that actually pay higher for out of network, but not many in my area. 

Michele
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PMRNC

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Re: In network or out of network?
« Reply #6 on: April 27, 2009, 07:09:22 AM »
You will also get lucky every now and again by negotiating with an OON plan to GET in network benefits. When I did ped's there were some carriers you could get to pay the circumcisions In Network.

Linda Walker
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Pay_My_Claims

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Re: In network or out of network?
« Reply #7 on: April 27, 2009, 08:42:00 AM »
OOUch @ circumcision!!!

dfranklin

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Re: In network or out of network?
« Reply #8 on: June 08, 2009, 04:26:23 AM »
I mentioned to one of my doctors who is all Non-Par about what I read here and that he would be more profitable if he became PAR...I used the example previously posted by "Pay_My_Claims"....here is what my doctor's response was:

"A solution to this would be to bill the Pt full fees, superbill them to submit to their Ins and notify the Pt that any reimbursement their Ins. company sends them - they keep. "

What should I say to that?  Seems like yeah..that is one way of doing it but I think he would end up with a higher patient A/R and/or a lower patient base as they will not all be able to come up with all the fees before service is rendered.....what do you think?

Wouldn't this also cut me out of the loop somewhat?  I guess I would bill on the upfront collection from the patient and then just submit the claim...I would not have to follow up as it would be the patient responsibility then as we would have no idea of the results....We would not be acepting assignment...

Responses?

THanks!

PMRNC

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Re: In network or out of network?
« Reply #9 on: June 08, 2009, 06:27:30 AM »
The doctor could tweak that idea and it could be done successfully but with the patient paying at the time of service, NOT waiting. Converting to a cash practice is not always easy, it takes the front office and the billing department on the same page as the doctor. If claims are high dollar, it might not work out so well because as you mentioned he's patient A/R would accumulate and it's harder to collect at that point. If he did assignment of benefits on the high dollar claims and the office verified benefits and eligibility, he could collect the out of pocket at the time of visit. Example: patient has Aetna, doctor is non-par, patient calls in for an appt, gives her insurance info, office verifies eligibility/benefits, office can then call patient, tell them to expect to pay $XX.XX and completes the paperwork with assignment of benefits as well.

As for cutting you out of the loop, it depends on your contract. If your contract is for a % of all revenue collected than it shouldn't cut you out, you will still be tracking the payments in order to keep the books properly. If your contract is for insurance payments only (I don't recommend this) than it gets sticky because who's tracking payments? My rule was, I track it I get paid, I've seen some offices keep track of their cash-pay and billing company keeps track of insurance, however then you have two sets of books and that's not good for any business, let alone a medical practice.
Linda Walker
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Pay_My_Claims

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Re: In network or out of network?
« Reply #10 on: June 08, 2009, 09:47:33 AM »
Thats true Linda, and in my business (high end rehab DME), its not always feasible to have a client pay up front. If you are talking general practice or some specialty, most patients will opt to stay in network because of the higher out of pocket expense. There are some patients that will stay with a provider that is out of network simply because they have been long time clients and unfortunately their job may have changed plans, and they just don't want to change physicians. Going to a more cash based business can be just as tedious.

PMRNC

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Re: In network or out of network?
« Reply #11 on: June 08, 2009, 10:12:14 AM »
Right, you definitely have to have the right practice, location and patient base. Lots of doctors are even trying out triage and there are some states/counties doing pilot programs where the patient pays one fee per year. But with each practice there is a LOT that goes into putting these models together, it's got to be the right time and circumstances. I have an old client I worked for a few years back, he went all cash, the process took him about 2 years to get moving because some of the plans he participated with had a wait period for him to get out of, once he got it rolling it was pretty smooth, he notified patients with several notices in advance. He now collects the payment before the visit (psychiatrist), his patients know this upfront and as a courtesy he files claim without AOB and patient gets reimbursed whatever their plan allows. His A/R last time I spoke with him was $490 and that was with a patient he has a hardship arrangement he's working with. I helped him with the leg work to get this rolling and he's never been happier. Now this type of situation is NOT for all providers, again, the time, the practice, ...everything has to be JUST right to do this and with some types of providers this just isn't going to be feasible w/out losing a big patient client base (DME, Surgical, even large family or GP)

Linda Walker
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Pay_My_Claims

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Re: In network or out of network?
« Reply #12 on: June 08, 2009, 06:33:24 PM »
You hit it on the nail. There are just some practices that doing that is very difficult.