I can't speak to facility reimbursements, but I have had some prior experience with physician side out of network.
Just knowing the insurance company does not always tell you the UCR. For example, 1 plan may use 150% of Medicare. Another policy WITH THE SAME INSURANCE COMPANY may use 120% of Medicare.
Whenever we contacted an insurance company to question out of network rates/UCR, etc, I was always told the patient should be paying the difference between our full charge and what the insurance approved and paid (with exceptions for emergencies). The insurance WANTS the patients to be balance billed, to discourage using out of network providers.
A previous practice had a whole legal issue, with a specific carrier claiming that if the patient did not pay the difference, they were going against the terms of their policy. We were not waiving deductibles or co-insurance, and properly notified the carrier that we were willing to negotiate the rates. The same carrier also refused to acknowledge assignment of benefits and would only make payment to the policy holder.
After that fiasco, here is my 2 cents about out of network. Only be out of network if you do not want to see those patients. You are willing to lose those patients because that insurance company will not work out a fee schedule you can agree to (or has some other restriction you will not agree to.) If patients with that insurance do want to come to your facility, treat them as self pay and provide the patient with the necessary itemized bill to submit on their own for reimbursement.
I would recommend trying to negotiate a contract you can agree to (often not possible, but worth a try). If unable to negotiate, decide whether the in network fees for the level of care you provide adequately reimburses or whether you would rather stay out of network and not have that patient. For us, there were some insurances with such low in network fees, we decided it was not worth the physician's time and practice expense and would rather not have that patient. If overall you have 10% fewer patients, but only 2% less reimbursement, that is not a bad thing.
Perhaps someone with facility experience could weigh in.
