For some specialists, the contracted rates for some insurance companies are too low. Specialists may request to stay out of network in order to maintain what they assess is a fair reimbursement for the treatment being delivered. Here’s how your practice should handle billing for an out-of-network provider.
How Going Out-of-Network Affects Your Patients
The higher fee may present a challenge for patients to accept treatment plans that aren’t at their insurance company’s contracted rates. But, the good news is that insurance companies still often cover a portion of the patient’s treatment. The patient portion ends up being a little higher but the advantage is that the specialist can deliver their quality of work comfortably.
If your practice matches with a specialist who would like to remain out-of-network with the insurance companies your practice is contracted with, it will be important for your team to communicate to patients the value of working with this specialist, whether it’s quality, convenience, or just preference.
How to Submit Claims Out of Network
- Be sure to use the Specialist’s UCR fees and not your own insurance fees.
- Attach the Specialist’s W9 to the first few batches of claim forms.
- Preauthorizations are highly recommended, at a minimum 3 weeks before the scheduled appointment. File the pre-authorization as soon as the patient is scheduled.
Offering Discounts to Patients
The practice is advised to try to collect the full UCR fee from the patient upfront. But if you decide to offer a patient a discount on the procedure fee in order to make the procedure more affordable for the patient, you also need to submit that fee to the insurance company. In other words, the discount must not come from the insurance company or the specialist, unless otherwise agreed upon.
Making a Decision
Going out of network might ruffle some feathers with your existing patient base. It might also mean the difference between matching with a specialist in your region or not. The team at Pair Dental can help you chart a path forward with the specialist to serve your patients. Simply let your member coordinator know how they can help.