Outpatient Facility Coding Alert

Question: What are some best practices we can follow for compliant out-of-network billing?

Ohio Subscriber

Answer: If you have compliant policies and procedures in place and you always follow them, you can protect your facility from allegations of improper billing and fraud when billing out-of-network (OON). You'll first want to make sure that you fully disclose your OON status to patients verbally as well as in writing. You'll also want to avoid waivers/fee forgiveness, increased payer charges, and payments to referring physicians. Here are some tips.

For waivers, you should:

• Make reasonable and consistent efforts to collect patient payment
• Have clear, written policies regarding hardship or prompt pay discounts
• Never advertise that your facility will waive or forgive payments.

For payer charges, heed the following advice:

• Be cautious about inflating your facility's rates
• Use the same charge amount on claims as you do to calculate patient payments.

For referral payments, you should be careful when contracting with marketing companies, especially those with physician entities behind them. Ensure the marketing company discloses what, if any, type of physician arrangement it has. If you are paying a marketing company a percentage of the revenue that their marketing generates, that could be interpreted as a kickback in some circumstances.  

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