Thinking of Going Out of Network? Follow These 3 Tips to Ensure Success

Be honest with your patients to guarantee a smooth transition.

More and more providers are questioning whether moving to an out of network situation with a payer -- or multiple payers -- is best for their practice. Becoming out of network certainly has pros and cons that you'll wish to weigh sensibly before coming to a decision. Read this expert medical billing article for more.

If you're considering a move to becoming a non-contracted provider, follow these three steps to set your practice up for success.

1. Assess Your Existing Contracts and Patient Base

Before your practice starts talking about becoming out of network with a payer, you must review your contracts. There are specific key areas to pay attention to as you go through the contracts like:

• Enhanced groupers
• Implant thresholds
• Procedure rates versus case rates
• Silent PPOs
• Reduction of state mandated fee schedules
• Claims filing limitations
• Penalty for provider termination.

Medical Billing Tip: You also want to determine how going out of network will affect your patients and, as a result, patient perception and satisfaction. You can still see patients with the insurance even if you go out of network with a payer, but if the patient's plan does not have out of network benefits, you will need to determine how to transition their healthcare to a participating provider.

2. Reflect on Renegotiation of Your Existing Contract

In case you're having trouble with a certain payer, it may be worth doing some negotiating before you decide on going out of network.

In case reimbursement is too low, you can attempt to renegotiate your contract or get certain carve-outs so that the fee schedule is exceeding your costs. In case you think the contract is not satisfactory, schedule a meeting with your provider relations representative to talk over your needs and decide if negotiation is a possibility. You may also wish to focus on re-training members of your medical billing staff to check that they are medical billing correctly and collecting all the reimbursement your contract permits.

3. Inform Your Patients of Your Decision

In case your practice weighs the pros and cons and decides that going out of network is best, ensure to inform your patients and clarify the reasons for your decision.

Adjust your written financial policy to visibly state how patient out of pocket costs will be billed and what medical coding or collection practices will be implemented.

Make this written information available to your patients, and consider posting a notice in your waiting room as well.

Be ready to answer patients who call about their description of benefits. You must have a script that everyone on your medical billing staff follows so that the clarification and the general message stay consistent.

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