Beyond Survive & Advance: Taking Your Practice Out-of-Network

The first in a new series focused on medical practice survival tactics and opportunities, “Beyond Survive & Advance,” will cover a range of ideas for practice leaders to consider in today’s evolving healthcare landscape. From going out-of-network, to learning how to get the most out of your payor contracts, and beyond, we want to help practice leaders move out of “survive-and-advance” mode and back into growing and thriving.

The idea of going out-of-network has created a sense of unease and even fear among many medical practice leaders and patients over the years. In my experience, however, taking this step for your practice can be a game-changer in a variety of ways—improving your practice’s bottom line and even your overall patient experience and satisfaction.

A medical practice can go out of network (OON) with a health insurance carrier/plan by taking a series of steps to formally end its contractual relationship with that insurance company. Below is a step-by-step guide to help navigate going OON with any insurance carrier. I’ve outlined a high-level and relatively standard approach here, so there will likely be some nuances that practices should consider based on the insurance carriers they work with and their patient population.

1. Review the Contract(s)
   Each health insurance company contract outlines the terms and conditions of being in-network. The first step in going OON is to review the terms of this agreement to understand the notice requirements, time frames, and any penalties for terminating the contract.

2. Understand Your Patient Population
   The practice (staff and providers) should understand the financial issues confronting your patient population. It’s important to understand and educate everyone in your organization on the financial impact of going OON for ANY patient—new or returning. Your team should also understand the benefits, with these patient financials as a backdrop.
   
   As a matter of course, everyone in the office, including providers, should be able to answer the following questions about your patient community:

• What’s the co-payment for an office visit to be paid by the patient to an in-network provider, based on various insurance carriers?
• Does a patient's insurance allow for out-of-network benefits?
• If yes to out-of-network benefits, what are the limits? What are co-payment and deductible amounts? What if there are no out-of-network benefits (e.g., HMOs)?

This information and context will help you and your team shape the message for patients that any extra money paid above their usual co-payment is worth it. I will share more about this in step 4 below.

3. Notify the Insurance Company
   Typically, the practice must formally notify the insurance company in writing of its decision to terminate the contract. This is often done through a letter that includes:

• A statement of intent to leave the network.
• The effective date of termination (which may be a few months in advance, depending on the contract).
• A request for confirmation that the insurance company has received the notice.

Some contracts may have a specified notice period—typically 30, 60, or 90 days—meaning the practice needs to provide advance notice to the insurer.

4. Communicate with Patients
   This is a critical part of the process. The goal is to retain ALL patients after going OON, and consistent, thoughtful messaging for your patients is of the utmost importance. It is at this point that the practice shifts into a new kind of customer service model. Every staff member and provider should be able to discuss the benefits of going OON, leveraging their understanding of your practice’s patient population to do so (see step 2).
   
   When in-network, a patient would call and be told when the doctor could see them. In an OON environment, it’s important to have increased flexibility, allowing patients to be seen when it’s most convenient for them. We have found that most patients are willing to pay a little more for the ability to control appointment timing.
   
   There are other strategies to employ, but the simple fact is: To be successful as an out-of-network provider, practices must be more focused on the needs of the patient than they previously were. It makes a difference.

5. Update Billing and Reimbursement Practices
   Once out-of-network, the practice will no longer be bound by the reimbursement rates negotiated with the insurance company; therefore, you can charge what you believe to be fair and appropriate for your services. Typically, payment must be collected at the time services are rendered and patients need to be made aware of this when scheduling the appointment.
   
   The practice will submit an insurance claim form on behalf of the patient, but it will be incumbent upon the patient to follow up, not the practice.
   
   
6. Address Any Legal Considerations
   The practice must be aware of any legal implications of going OON. For example, some states have laws that restrict balance billing (especially in emergency situations) or impose certain requirements for notifying patients. But, generally speaking, there are few rules, laws, or regulations that would prevent a practice from going OON or impinge on their right to charge a fair rate for their services.

It’s true that going OON will take effort and coordination across your practice. Getting your organization engaged and having the right messaging for patients are both critical. But, with insurance reimbursement rates not where they used to be (among the many other pressures that independent practices are facing right now), I firmly believe this is an avenue more practices should be exploring.

To find out more and learn how Curi Advisory’s Practice Consulting group can help with going out-of-network, contact me at jeff.hollis@curi.com.

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