Author Topic: a question on out of network  (Read 2442 times)

jeannie

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a question on out of network
« on: September 16, 2008, 06:48:47 PM »
The treatment center I will be billing for has made what is in my opinion a bizarre decision today. They want to be out of network with every insurance. They are under the opinion that out of network will pay them better. Being in billing for 23 years my position has always been you will see more patients if you are in network because the patient will be liable for less. My question is this - do all insurances allow you to bill them if you see their patient and you are not in their network? thanks!

Michele

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Re: a question on out of network
« Reply #1 on: September 16, 2008, 08:58:07 PM »
Many of the drug & alcohol treatment facilities are out of network.  Usually it is because they do not meet all of the requirements to be in network, such as having the correct type of provider on staff.  I haven't heard of one being non par because they think the reimbursement will be better.  You might want to contact one or two of the major insurances carriers they bill to and ask for the difference in reimbursement for in and out of network.  Maybe if you get some definitive numbers you can help them to realize what will be in their best interest.

Personally, I agree with you.  I would think it would be harder to attract the patients if they have to pay out of pocket.  However, in this particular situation they have the patient over a barrel.  Usually it's a crisis and they have no choice.

Good luck
Michele
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ssukkar

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Re: a question on out of network
« Reply #2 on: October 21, 2009, 09:06:37 AM »
This is a similar situation that we find ourselves in.
We are currently out of network (OON). The reasons are that we are plastic surgery providers and the reimbursements we got under the contracted rate were ridiculously low. Since we do not do alot of volume like other doctors, it made no sense to continue in-network. Now we get paid in the 70-80% range instead of20-30%.
Since we have switched to OON, we do see far fewer patients, but the revenue is actually better. I estimate that I would have to see, take care of and perform surgery on 10 in-networks to every 8 OON.
If everyone would do this, it would force the insurance companies to play fair and reimburse at a more reasonable rate.
This strategy does not work for everyone, and it only works when the patient does not have an overly onerous OON deductible.

PMRNC

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Re: a question on out of network
« Reply #3 on: October 21, 2009, 09:14:39 AM »
Depends on many many factors. One size does not fit all. I can tell you that each practice who makes this decision to take a year to gather data, analyze and seek professional assistance, also it helps to have a practice marketing plan in place and all your ducks in a row before making this drastic change. I've seen it done successfully and I've seen a few practices go under because of not thinking it through and researching and looking at all the data.
Linda Walker
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ssukkar

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Re: a question on out of network
« Reply #4 on: October 21, 2009, 09:49:22 AM »
I meant to say 1 OON for every 8-10 in-network. Since we do not do high volume, there is no way we can generate the same revenue being IN-network due to the lack of volume.
I do mosly cosmetic, so the insurance work I do, I look upon as gravy.

I am trying to explore billing a facility fee for my AAAASF certified OR but have not made much progress as noone seems to know the rules or answers to make it work.

Pay_My_Claims

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Re: a question on out of network
« Reply #5 on: October 21, 2009, 12:39:19 PM »
if OON, you really need to have your ducks in a row especially your UP FRONT COLLECTIONS!!

PMRNC

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Re: a question on out of network
« Reply #6 on: October 21, 2009, 07:29:24 PM »
Quote
I do mosly cosmetic, so the insurance work I do, I look upon as gravy.
   :-\ :'(

Quote
I am trying to explore billing a facility fee for my AAAASF certified OR but have not made much progress as noone seems to know the rules or answers to make it work.


So you want to DE-Credential with carriers but bill facility and professional component? Sure you can. Assuming you have setup a proper legal structure to do so you can. Your facility charges will get billed using UB form and proper revenue codes and your professional fees will still be billed on CMS 1500   When out of network your not dealing with fee schedules HOWEVER your dealing with something I think is worse.. Reasonable & Customary or U/C Usual and Customary, that means if you bill out a Surgery at $10 K the insurance tells you what's R&C U&C and the rest is patient responsibility.. Don't know about you but I'd rater take my chances with a fee schedule than to ask the patient to pay $5K and end up spending most of your time dealing with collection agencies. Sure you can appeal and you might win some, lose some, get a little more, but again, more time = More money out.
So while it might seem like gravy to you, make sure you have really ran the numbers, gone over the fee schedules, the allowable and the patient aging reports for the past year (at least).  Now as far as the facility. .I would imagine you have to meet a lot of special requirements in order to do this so I would suggest a good attorney to guide you.

Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com