Sunday, August 31, 2008

Q. Is it really that bad to be an out-of-network provider?

A. While this may not be an option, depending on the region you do business in and the payer mix you work with, more providers are opting to be out of network. Probably the most important reason is that some insurers have higher reimbursement for out-of-network providers. This can result in your claim being processed based on your billed charge as opposed to your contracted allowable. Another bonus: You have a more expansive network of insurers to work with, which could result in more referral business.

To know whether this is a viable option for your business, be sure to conduct due diligence upfront by asking insurers: Are there out-of-network benefits? If so, what are they?

If you have determined there are out-of-network benefits, you will need to decide how you are going to handle patients. Are you going to bill patients the difference between their in- and out-of-network deductibles and co-insurances? Or are you going to bill them only what they would owe if they went to an in-network provider?

In either case, you will need to notify patients to avoid confusion if their explanations of payment don’t match what you’re billing them.

Another item to consider when billing as an out-of-network provider: Who will get the payment? If you know the patient will receive the money, you should bill the claim non-assigned so the accounts receivable is booked to the correct payer.

By knowing this critical information you may have opened another revenue stream that you have previously avoided.

Lisa Cusick is the corporate consulting manager with Bargmann Management, LLC. Reach her at <a href=