September 8, 2021

Are you better off going out of network?

If you have some unique advantage as a practitioner compared to your peers and are in high demand, it might make sense to go out of network with poor-paying carriers.

In some cases, you may be forced to go out-of-network by carriers who thin down their provider roster or force unreasonable fee schedules.

Making a decision to go out of network involves several factors:

  • Paying capacity of the patient base who will be balance billed
  • UCR (Usual and Customary Rate) caps on fee schedule with the carrier
  • Federal and state regulations on balance billing
  • Billing process changes to handle out of network payments and private fee agreements

All factors have to be considered carefully before electing to go out of network. Sometimes it may be prudent to negotiate with the carrier before making a decision.

Finally, patient perception is very important. You have to make sure that your out-of-network fee schedule is reasonable and can withstand scrutiny. Patients also have to be provided a clear estimate of their out-of-pocket costs prior to services.

All things considered, going out of network (either by choice or by force) can have significant financial implications - positive or negative and has to be carefully managed.

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