In today’s healthcare environment, doctors need an equitable stand on payer negotiation and therefore there may seem to be no need to go Out of Network. However, organization goals, personal preferences of physicians, and the typical cookie-cutter contracts that Payers force on physicians leave practices with little choice but to walk away from Insurance Networks.
Some savvy business planners negotiate with Networks by threatening to go out of network, hence can end up with improved reimbursement rates, but this is a rare case.
Physicians are opting more and more for preserving the Out of Network option because of social media and internet search capabilities that lead to a competitive landscape where patients can pick and choose the physician they like. With hospital affiliated groups, this is especially true if the hospital’s patients have the flexibility to receive the services provided by physician groups at another practice, such as a competing physician group, ambulatory surgery center, or imaging center.
Nonetheless, there are expert legal consultants that advise groups to not immediately agree to facility terms that prevent the possibility of going out-of-network. Doing so unilaterally diminishes the negotiating leverage a practice may need at some future point with a payer.
These legal experts have helped scores of physicians when Networks refuse to negotiate in good faith, if they offer non-competitive rates, or in those instances when payers notice of their intent to decrease the physician’s fee schedule. This is becoming common especially in government networks such as Medicare and Medicaid. Government contracted Networks such as Humana Gold and BCBS Medicare Advantage Plans have started to allow Out of Network physicians to treat their members.
Out of Network physicians can derive compensation at the time of service rather than wait for reimbursements to come. As a result, there is increasing need for physicians to find a way to help patients seek reimbursement. At most practices, physicians can hand a patient an itemized receipt (or superbill), but the patient is then lost as to how to move forward from there.
An emerging space in the health tech industry is helping patients do just that. Submit their Out of Network claims easily through online platforms and apps. For example, Oonology, helps patients and physicians nationwide providing Out of Network claim reimbursement services by sending claims to Payers on behalf of patients at a very reasonable cost.
With more and more physicians and practices heading toward Out of Network services, there seems to be more and more space in the industry to help the patient navigate a confusing healthcare landscape.Back to blog