Patient Prep Key to Being an Out-of-Network Provider

January 10, 2015

Having a solid plan in place and not panicking is key when you find yourself suddenly out of network with a popular insurance company.

Most often, practices know when their insurance contract is up for renewal or negotiation. If there isn't anyone in your practice keeping an eye on this, however, finding yourself suddenly out of network with a popular insurance plan can be rather bothersome and very frustrating.

The first thing you want to ask yourself is, "Do you want to re-sign with this plan given the current reimbursement rate?" If the answer is yes, get on the phone and sign up with them as soon as possible. Find out the date that the contract ended and try to negotiate a back date on the reinstatement of the plan (i.e., January 1).  Most likely, claims have already gone out and are being processed at the insurance company under your out-of-network rate. This means that if you do end up getting a back date, those claims will need to be refunded to the insurance company and then rebilled under the in-network rate.

Why go through all of this trouble? Your patients are receiving explanations of benefits from their insurance company showing their patient cost-share is 40 percent co-insurance instead of a $20 copay. Depending on how you code, this can be a significant amount to a patient on a budget. Oftentimes, out-of-network benefits also include a large deductible that their in-network plan does not have. Now you have a confused and angry patient calling your front-office staff or billing department and yelling at them for not being told you were out of network.

If you decide you do not want to sign back up with the insurance plan for whatever reason (low reimbursement, you're the only physician in the area that would be accepting the plan diluting your patient population with this particular plan, etc.), you need a solid plan to see patients under their out-of network-benefits.

Here are four steps you can take:

1. Draft and mail a letter to every patient that you have seen with this plan from the past year. Let them know you are now an out-of-network provider for their plan. (If they have changed insurances to an in-network plan, you can still see them under that in network plan.)

2. Explain to your patients that because they now have out-of-network benefits, you can see them with those benefits or they can become a cash-paying patient. Because you do not have any type of contract or legal agreement, you are welcome to see patients as a cash-paying patient.

3.  Be sure you tell the patient what those out-of-network benefits are, so they are aware when they come in to see you. This is typically done prior to a patient's visit anyway, so the choice can be made at the visit or calling the patient before the visit and letting them know their options.

4. Write a "script" for your front-office staff explaining how they are to present this information to the patient. Some people are better at "selling" the practice than others are. Take lessons from them! Have them help with the script and training to those who are not so versed in sharing how great your practice is and why its worth it to come and see you instead of an in-network provider.

Either way, it's rather painful when you find yourself in an out of network situation. Always keep up with your contracts and if this happens, don't panic. Just implement a solid plan and follow it.