Medicare Compliance & Reimbursement

"Generally patients with no out of network benefits will be directed to another facility," Maycock explains. "Assisting the patient in that transition and providing clear communication on the reasons non-participation became necessary is crucial to maintaining good will."

"One of the reasons that more providers are considering taking the step to remove themselves from their contracted status is the constant reduction in contracted reimbursement," Maycock says. "The insurers are giving providers a smaller and smaller piece of the pie while they're collecting record profits. Insurers typically reimburse using packaged reimbursement formulas that often do not cover the cost of providing quality patient care. An out of network strategy often provides the only opportunity to control reimbursement and provide a more stable financial platform for providers."

If you're having trouble with a particular payer, it may be worth doing some negotiating before you choose to go out of network.

If reimbursement is too low, you can try to renegotiate your contract or get some carve-outs so that the fee schedule is above your costs. If you think the contract is not acceptable, schedule a meeting with your provider relations representative to discuss your needs and determine if negotiation is a possibility. You may also want to focus on re-training members of your billing staff to confirm that they are billing correctly and collecting all the reimbursement your contract allows.

Often, if you let your payer know you're thinking about becoming out of network, they will take some time to negotiate with you. "Once you've established with your payer that you're going to be terminating the contract, they will provide their best offer," Maycock says. "Then you can determine if an on-going contracted relationship is financially viable."

If your practice weighs the pros and cons and determines that going out of network is best, be sure to inform your patients and make clear the reasons for your decision.

Modify your written financial policy to clearly state how patient out of pocket costs will be billed and what collection/billing practices will be implemented. "It is key that it be written and followed without exception," Maycock warns. "If you have a stated policy and all patients are going to be billed as if they were in network when it comes to copays and deductibles and coinsurance, but you've not written that as part of your financial policy, it's not considered to be part of your financial policy.

Make this written information available to your patients, and consider posting a notice in your waiting room as well.

Bottom line: "Being upfront and open, addressing patient concerns, and thoroughly training your entire staff on the new process is the key to making sure your patients are comfortable and your transition to out of network is successful," Maycock says.