Physician Provider Going Out of Network with the Insurance Company | Think Again

Going Out of Network with the Insurance Company, think again (especially when you are a Primary Care Provider)

Physician Provider Going Out of Network with the Insurance Company


How long ago have you revisited your contracts? when was the last time you have reviewed your contracts? – maybe 3, 5 or even 10+ years ago?).

Three biggest reasons why provider would pursue going out of network:

1. If you are no longer happy with your payers’ contracted rates or because the contracted rates keep on changing;

2. Timely filing limit policy is also one reason;

3. Reimbursement Policy Guidelines (bundling services into one payment);

But Before you go out of network, here are the things you might consider and take a look at:

1. As you know, not all your patients have an out-of-network benefits. You have to understand that because of this, your existing patients must be transferred to another provider or facility that accepts in-network benefits. Otherwise, out of network deductible/coinsurance will apply towards your patients’ responsibility;

2. Your patients population will likely decrease due to patients’ being without an out-of-network benefits.

3. Some insurance company would send the payment check for your rendered services made payable to their member or your patient because you are an out-of-network provider (isn’t this so true?);

4. When you are following-up on claim status, some insurance company will not disclose a more detailed information regarding the claim status (especially denial and rejection) not unless the patient (their member) will call them; (reality! – hold time for out-of-network provider on the phone is probably 20 minutes minimum!) – isn’t this true? Who had experienced this? (please share your thoughts below on the comment box);

I do think the best action to do it — before terminating your contract with the insurance company is to try to NEGOTIATE first. Our company can help you with the process in negotiating with the insurance payer. Contact us here.

Talk to your provider relations manager in the area. Discuss your intention of going out of network and ending your contract. Tell them your reasons why you want to terminate the contract.

I know the insurance company will be willing to negotiate your contracted rate or your entire contract as a whole! Especially if they know it will affect their “members” — your patients!

Now, if in the end, you still have decided to terminate the contract. Just make sure you inform your patients ahead of time and bluntly explain to them your reasons why you are terminating the contract with their insurance company.

Explain it to the patients what and how this will affect them. The financial responsibility they might incur for being out of network. Let them sign your financial policy and let them understand fully the policy. If they decide to go somewhere else, you have to assist and help them move to another provider or facility who is in network with their insurance company.

Now with regard with the patients who has no out-of-network benefits, make sure you assist and help them move to another provider or facility who is in network with their insurance company as well.

The true concern here are your patients. Let them understand the situation if they go out of network. I think a good, clear and open communication with your patients is very important as you become an out of network provider for your patients.

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Good luck. I hope this article helps.




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Author: Pinky Maniri

Ms. Pinky, as she is fondly called - is a Reputable Professional Consultant and Expert in Practice Administration, Medical Billing, Coding, Health Information Technology, Insurance Credentialing and Compliance for Physician Offices. Well-educated with a Degree in Computer Systems Engineering and a background in Clinical Nursing and Small Business Management. Her professional mission is to make sure her clients/physicians maximize reimbursement while they remain compliant with the current rules, changes, guidelines and policies. Read More About Ms. Pinky here and See what Other's say about her Expertise Testimonials

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