Out-of-Network provider

Out-of-Network provider (Full Version)

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PamPT -> Out-of-Network provider (November 13, 2007 2:19:14 PM)
Just curious to know what it means to you all out there to be an out-of network provider?

SJBird55 -> RE: Out-of-Network provider (November 13, 2007 8:01:49 PM)
From an independent physical therapist perspective providing outpatient services in private practice: An out-of-network provider has no contract with the third party payor. Since there is no contract, the provider can capture the full billed amount for services provided, can collect the money up front and doesn't have to follow rules and regulations of that third party payor. (This means documentation rules for that payor do not need to be followed.) The provider just has to worry about the rules and regulations for his/her particular practice act. There is one qualification or exception... if one is out-of-network for Medicare, there is a maximum amount that those patients can be charged for services. As an out-of-network provider, the provider does not have to submit claims and can provide a completed 1500 claim form to the patient to send in to their insurance company. As a provider, you can choose to complete and submit the claim forms on behalf of the patient. If you as an out-of-network provider choose to accept checks from the insurance company for services, then on the claim form there is a box you tag to indicate that and then you need a signature on file from the patient to allow the insurance company to send you the check. After you receive the check, you can bill the patient for the outstanding balance. If you do not want to accept checks from the insurance company, you do not tag that box on the claim form and the third party payor cuts the check to the patient. When a provider is out-of-network, the patient incurs greater financial responsibility and sometimes penalties for choosing an out-of-network provider. What does it mean to you to be an out-of-network provider?

PamPT -> RE: Out-of-Network provider (November 13, 2007 8:39:01 PM)
I am considering starting a small private practice and am considering different patient pay options. Often I read threads throughout this forum regarding reimbursement and lack there of. Doing some research and reading about the headaches associated with being an in-network insurance provider, I often ask myself why be bothered. I'm sure patients would prefer to not have to pay out of pocket for any service, even though they are benefiting from the service. I have seen/heard/read about out-of-network providers. Being an insurance carrier myself, I know that means the insurance will usually pay 40-60% of the service. I myself have paid out-of-pocket for medical services out of network. I guess being on the other side of that relationship, I wondered if as a courtesy, PT's can submit the claims for the patient or choose to have the patient submit the claims themselves. I would prefer to get paid for the services that I bill for, instead of having it sliced up by the insurance company. My goal would be to be driven by the care I provide and increasing patient outcomes/satisfaction and not be driven by insurance companies. Thank you for your post.

SJBird55 -> RE: Out-of-Network provider (November 13, 2007 11:09:40 PM)
When considering out-of-network.... also remember that our services are more than a one time visit. Also, you would potentially want to know the mix of payors in the area. Some contracts have large deductibles for out-of-network (anywhere from $250-1,000) and sometimes have up to a 20% penalty. Sometimes after the deductible is met, the patient then has a 20% co-pay (as an example) on what is "allowable" for the specific procedural code. When you compare the out-of-network to the in-network, there may be quite a difference - sometimes no deductible and no co-pay to a no deductible with a $0-$20 co-pay or a certain deductible and then no co-pay. You can definitely be driven by the care you provide, but at the same time, look at your population mix and their income levels and whether there is a perception of value to the service you provide. Utopia would be that no one would participate and then the patient is left to choose... that isn't realistic though. You can submit claims for the patient.

PamPT -> RE: Out-of-Network provider (November 14, 2007 7:17:18 AM)
Thank you for all of your advice and knowledge. It's all very helpful. How do I inquire about the mix of payors in my area?

SJBird55 -> RE: Out-of-Network provider (November 14, 2007 4:40:00 PM)
I never had to actually do that because I currently practice a 1/2 mile down the road from where I practiced previously for 6 years (meaning, I already knew the mix of payors in the area). I guess what I would do, if you are near a large hospital system, that kind of a payor mix would be present. Look in the internet for job opportunities or call human resources to see what kind of benefits are available for employees. Blue Cross is generally a large mix, contact a provider consultant... express your interest in considering being in-network with them and that you'd be interested in knowing what type of BCBS plans are in your zip code to see if there is a substantial amount of subscribers living in the area. If you are thinking of locating near an industrial park... then you'd also need to see what kind of benefits the companies have for employees. Human resources might be helpful to you. When you ask about benefits, you'd also need to know specifics - in and out of network benefits, authorizations, number of visits, capped amount of visits... So, I guess, a BCBS provider consultant OR enrollment person.... human resources within large local companies.

PamPT -> RE: Out-of-Network provider (November 14, 2007 5:47:43 PM)
SJBird, Do you practice as an out-of-network provider?

SJBird55 -> RE: Out-of-Network provider (November 14, 2007 10:12:34 PM)
There are all sorts of contracts out there. I'm in-network for some and out-of-network for others. I can count on my 2 hands the number of times someone was out-of-network chose me for their care. When the patient is educated on options, with some of these plans, it really is a no brainer if finances are an issue. The ones that choose to come are generally financially secure. I'm in MI and in my locale (with lots of jobs gone and the automotive world going through tough times) most people choose to save money and pay the least amount out of pocket as possible. I honestly can't blame them - when the future is unknown and plants are shutting down, well... one has to do what is right for one's family and let's just say that more often than not the priority isn't with physical therapy. If the people living or working in the area you plan on having a clinic are of the same mentality, a big obstacle to overcome is having the volume of patients attending to sustain your business. My clinic is not in the kind of geographical area that self-pay or out-of-network status is going to happen at a high frequency.

hmgross -> RE: Out-of-Network provider (November 24, 2007 1:28:45 PM)
SJ, agree with you on the out-of-network considerations. I too work in an area that is a bit "depressed" in northern MN and people tend to forego RX if insurance doesn't cover. It's not just us--Dentists here are pretty affected when people lose jobs/benefits. I was in the same situation where I worked just down the road at the hospital as the therapy director so I had a pretty good feel for the payor mix. Generally speaking, I am about 1/3 each medicare, BCBS and work comp. I also run a reimbursement analysis a few times a year from my billing software so I can track what some of the smaller payors are doing and may make decisions on going out-of-network with them.

Nicole Matoushek PT MPH CSHE CEES -> RE: Out-of-Network provider (March 21, 2008 10:25:07 AM)
THis is a great thread!

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