Benefits of Out of Network status

For many medical providers the age old question is, "should our practice be in or out of network?" The answer depends on your location and specialty. By this we find general primary care providers in large metro areas choose to be in network because limited payers, such as BCBS, Medicare and Medicaid and in competition for the same patients. Where patients are less restricted many medical practices find being out of network has advantages such as higher reimbursements for the same in network contracts. Probably the two highest drawbacks are the following:

                        -Higher Out of Network Deductible

                        -Paying the patient direct which hinders collections efforts.

Below are a number of reasons why a provider would opt Out of Network:        

-In network, PPO contracts do not guarantee an influx of new patients to offset discount. Many times the practice patient base remains constant.

-Once signed, the practice must accept patient from the plan and fee schedule mandated by the insurance company which typically in the favor of the insurance carrier.

-Patients may assist in low payment appeals because they may be ultimately responsible for the balance.

-Typically payments are or above 60% of billed charges well above Medicare plus contracts.

In conclusion the provider needs to understand the patient population and how its services caters to their needs. A thorough understanding of this will give the practice an advantage over competition.