in network vs out of network | In Network vs. Out of Network | STATMedCare Payor and Physician Enrollment and Credentialing

Ding-Ding-Ding.  The fight of the century is about to take off.  The battle of two different heavy weights.  In the left corner we have the “In Network” coming in with low cost, and easier to manage and delegate.

In the other corner we have Out sourcing (Out of Network), which is known for expertise, and efficiently.  Let’s see how who comes out as the champion.

  1. Logistics

If you are currently in network, choosing to go out of network requires a few things. In most cases, you must give the payor at least a 30-day written notice. This will allow them to inform all patients who have seen you in the last two years that they need to find a new physician or pay out of network rates. You will also need to inform your patients, in writing, of the change to your policy.

  1. Reimbursement

Currently, if you are in network with the payor and want to go out of network you have to consider that most patients will not see an out of network provider and will choose to go elsewhere for their care. Do you have a plan in place to speak to your patients about staying with you? Do you know how to explain the increased costs they should expect? Do you have a plan in place to recruit new patients who are okay with paying out of network rates?

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  1. Balance Billing

One of the key advantages to going out of network is the ability to balance bill your patients. For instance, when you were in network and submitted a bill to Cigna for $300, the EOB that came back would say the allowed amount was $105.00 and the patient responsibility is $25.00 for their copay. So Cigna would pay you $80.00 and you would collect the $25 copay from the patient. The remaining balance of $195 is your contractual obligation and you MUST, per your contract, write this amount off. Now, if you were billing out of network you would contractually be allowed to “balance bill” meaning you would bill the additional $195 to your patient. Knowing and understanding how balance billing works is a key component to deciding if you will be in or out of network.

  1. Contractual Considerations

Currently, if you are in network and choose to go out of network, you may have a very hard time getting back into the payor network when you decide you again want to negotiate a new contract and be in network. Often, a physician will threaten to leave the network if the payor will not renegotiate a new contract with them. This is often a tactic that can work well, but only if you truly know how to negotiate a contract and exactly what they are looking for. This is most often best left to a professional credentialing company. If you are deciding to leave a network simply because you are unhappy with your reimbursement, consider hiring a credentialing company who has solid experience and success in negotiating new insurance contracts.

red boxing gloves | In Network vs. Out of Network | STATMedCare Payor and Physician Enrollment and Credentialing

Understanding the considerations above can help you make a more informed decision, or at least have a better understanding of what implications this decision will have, regarding the future of your healthcare business. For help in making an in network or out of network decision, you should always contact an experienced credentialing company who can help you evaluate the pros and cons of this major decision.

 

STAT MedCare Solutions has been around the block for the past 14 years.  Our mission is “providing client services on a foundation of trust and integrity.” Let us share one of our professional tools with your practice as well, so you can compare it to or add to your current credentialing process:  Here is a free copy of our Provider Enrollment Checklist.

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Have a Good Day from everyone at STAT!