Don't have a TCI SuperCoder account yet? Become a Member >>

Regular Price: $24.95

Ask An Expert Starting at $24.95
Have a medical coding or compliance question? Don’t sacrifice your valuable time to endless research. Choose Ask an Expert to get clear answers from the TCI SuperCoder team. And here’s a tip for the budget-conscious: Select the 12-question pack to get the best rate per question!

Browse Past Questions By Specialty

+View all

Out of network vs. In Network benefits

Annette Posted Thu 14th of July, 2011 12:51:30 PM

We need to opinion of others regarding an Ambulatory Surgery Center accepting in-network patient responsibilities when they are really out-of-network. Is this legal? See article below.

Patient Discounts:Tips to Keep Your Practice Compliant
Posted By ~On November 2002 @ 12:00 am In Billing & Collections I No Comments

Out-of·Network-Penalty Relief: Honesty is the best policy for allotting discounts as an out-of-network provider. Come clean when you eliminate the out-of-network penalties that patients incur by consulting an out-ofnetwork provider. "You want to somehow alert the payer to what the situation is" so the payer can decide payment on your actual charges, Sarraille says. In doing so, you have not "pulled the wool over their eyes in any way," he says.

Third-party commercial payers voice complaints when you help their clients and not them with this cost of service.The typical third-party quibble happens when you charge patients the cost an in-network provider would charge and then bill the payer the standard charge, not showing the discount as listed, Sarraille says. These alleged cash discounts aren't really even discounts, as they're typically called.
They are a guise that makes the out-of-network penalty negligible, Sarraille says. The discounts reduce the services charged, balancing out the penalties that patients incur for using an out-of-network provider. With the discount, the out-of-network provider gets
payment from a patient who otherwise might have chosen to avoid penalty and go somewhere else. You may tarnish your reputation by providing incentives to patients that encourage them to avoid their carriers' rules. Plus, you risk violating anti kickback laws.

Any documentation would be helpful!

SuperCoder Answered Fri 15th of July, 2011 18:25:22 PM

We have passed this information to the concerned Editor, and will get back to you soon.

SuperCoder Answered Fri 15th of July, 2011 18:31:49 PM

As the article indicates, you need to notify the payer that you will accept the patient's in network benefits, including any copayments and deductibles. You must charge the patient their portion of the charges as indicated by the payer.

The payer may decide they do not want to "play along" and still process the claim out of network, which will hit the patient's out of network deductible which is likely to be higher than the in network deductible and will cost the patient additional out of pocket funds. You are required to follow the EOB, holding the patient responsible for the "Allowed Amounts" on the EOB, but you do not have to charge above and beyond the "Allowed Amount", which is usually the insurance company's "R&C". You can write off the difference between your full fee and the "allowances" or "R&C" If the allowances are low, you can also assist the patient by appealing to the payer, holding them accountable to prove that their allowances truly represent "R&C" and you will find that you can often get the payer to pay additional funds.

But keep in mind that higher deductible for out of network. I would get the payer's "permission" and ok to process as in network prior to the surgery. Out of network deductibles can run from $7500 to $10000 or more. One of the reasons payers might not cooperate with processing as in network as they want to hold out to get your facility to sign up to be an in network provider for all patients.

Related Topics