Managed Care Contract Negotiations
Apr 09

Seeking payment as an out-of-network provider

Out-of-network providers often struggle on two levels to collect payment. First, the amount of money providers actually receive is an issue because sometimes the payer tries to pay using an alternate fee schedule instead of your billed charges. Second, providers often have a difficult time getting paid directly because many payments are instead sent directly to patients.

The following tips include alternatives to explore when seeking payment as an out-of-network provider.

Providers considering going out of network should check whether the payer might also use a national network in their area. You can receive national network rates, which are higher than what you would receive as an out-of-network provider.

Pouring resources into seeking payment for billed charges from the plan often has a low success rate. Instead, ask the patient for a deposit up-front.

Take things a step further and seek payment in advance from the patient.

Learn about your state’s insurance laws. State laws are critical for out-of-network providers. When it comes to seeking payment for services, there could be specific language stating that payers must send payment directly to providers and not to the beneficiaries.

Approach your state medical society or hospital association and voice your concerns.

Even if your state doesn’t have applicable laws on the books, ask your attorney to check out case law in your state. It’s possible that this issue has come up before, and there might be a case in which the decision set a precedent.

Providers considering going out of network should check whether the payer might also use a national network in their area. You can receive national network rates, which are higher than what you would receive as an out-of-network provider.

·  Pouring resources into seeking payment for billed charges from the plan often has a low success rate. Instead, ask the patient for a deposit up-front.

·  Take things a step further and seek payment in advance from the patient.

·  Learn about your state’s insurance laws. State laws are critical for out-of-network providers. When it comes to seeking payment for services, there could be specific language stating that payers must send payment directly to providers and not to the beneficiaries.

·  Approach your state medical society or hospital association and voice your concerns.

·  Even if your state doesn’t have applicable laws on the books, ask your attorney to check out case law in your state. It’s possible that this issue has come up before, and there might be a case in which the decision set a precedent.

About Reed Tinsley, CPA

As a top advisor to physicians, I help increase practice profits by delivering hands-on, expert medical accounting/tax support, practice counsel, and revenue-building strategies. Read more →