President of American National Medical Management, Greg Maldonado, discusses five reasons why ambulatory surgery center owners should not sign in-network contracts.
1. Once a contract is signed, providers are bound by the insurance company's terms. As long as physicians and surgery centers remain out-of-network, they retain all legal rights under federal and state laws to negotiate reimbursement on behalf of the patient. If the physician or surgery center chooses to sign an in-network contract, the insurance company retains all legal rights to dictate fee schedules, materials covered and medical necessity criteria.
"Understand what insurance companies deem investigational and experimental," says Mr. Maldonado. "Ask questions, because if you don't ask, they won't tell you. With most private health insurance companies, the contracts will be one-sided in favor of the payer."
Staying out-of-network allows providers to utilize federal and state laws to hold insurance companies accountable for timely and accurate reimbursement. Research the new healthcare laws or hire an ERISA expert to help your group negotiate maximum reimbursement on out-of-network claims.
2. Your patient base will not increase just by signing a contract to be in-network. Many providers believe that insurance companies have the largest impact on how a patient will find their doctor. However, studies show that patients are more likely to find a provider via a friend or family referral than to enlist the help of their insurance company.
According to the Center for Studying Health System Change, nearly 70 percent of patients' chose their specialist based on referral and only 11 percent of patients were actually referred by their health plan. Additionally, 74 percent of patients chose their procedure facility based on referrals, while a mere 7 percent reported consulting their health plan on this issue.
"Providers believe that going in-network is essential to obtaining patients," says Mr. Maldonado. "The reality is that most patients, when seeking a specialist, ask their primary care physician, or a friend or family member for a recommendation. Patients are seeking quality, not networks. When a physician or surgery center chooses to be out-of-network, creating an effective marketing plan to reach primary care physicians is essential to success. Effective marketing will increase patient load without the headaches of in-network contract obligations."
3. Providers do not have negotiating power; patients do. Because the patient is the one subscribing to the health plan, they hold all the power when negotiating with insurance companies. There are laws in place at the state and federal level that insurers must follow, and patients have the power to utilize those laws. Most patients do not know the power that they hold and the insurance companies use that to their advantage.
"Providers think they have negotiating power, but according to the law, only the patient has the power to negotiate and appeal a claim," says Mr. Maldonado. "Remaining out-of-network and harnessing the power of the patient, allows the provider to hold insurance companies accountable on the patient's behalf. Understanding how payments are derived and negotiated gives the provider an opportunity to increase revenue while decreasing or eliminating the patient's out-of-pocket costs."
Learning about reimbursement and the laws that govern it will improve any medical business. Hiring a professional to navigate these laws allows surgeons the freedom to practice medicine without the fear of losing reimbursement. "These laws will impact the physician's livelihood; take the time necessary to either learn the laws or hire an expert," recommends Mr. Maldonado.
4. Insurance companies enforce anti-assignment clauses for in-network providers. Providers who go in-network with insurance companies that have anti-assignment clauses face strict rules regarding how reimbursements are paid. As a result, they may receive sub-par reimbursement or no reimbursement because the checks are sent directly to the patients and never make their way to the provider.
"The anti-assignment clauses and policies are governed by federal and state laws," says Mr. Maldonado. "There is a three-pronged approach surgery center owners can take to remain out-of-network with insurance companies that have anti-assignment clauses."
• Manage your patients — Many times patients have never received a check from their insurance company before and they don't understand what they are supposed to do with the check. Some may assume it is a reimbursement for overpayment and that it is their money to keep. Give them appropriate expectations and let them know that they will be receiving money that is meant to pay for surgery, not for personal use.
• Have paperwork signed by beneficiaries — Make sure there are proper benefits assigned for the patient and go over the appropriate documents that are essential for defeating anti-assignment clauses.
• Educate insurance companies on anti-assignment — let them know that you are aware of the state and federal regulations, and expect them to follow the law.
5. True success comes with a balance. A truly successful practice will have a payer mix. Find the right balance for your surgery center to diversify claims and increase reimbursement.
"Understand the market and know what procedures are best reimbursed in- and out-of-network, and do a comparative analysis," says Mr. Maldonado. "Once you can identify all the benefits a patient has, create a game plan for that patient. If the provider has a well-balanced model where patients can use their out-of-network benefits in instances where it makes the most sense, the provider is guaranteed a successful practice."
Educate patients on their options; they like knowing they have made the right decision. Partner with them to overcome the "myths and fears" that insurance companies place on utilizing their out-of-network benefits. The patient pays for those benefits and has every legal right to use them, says Mr. Maldonado.
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