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COVER STORY


Going Out of Network


Benefits and drawbacks BY SAHELY MUKERJI


I


n April, insurance giant Aetna won $37.4 million in a jury verdict against


Bay Area Surgical Management (BASM), based in Saratoga, California. The 2012 law suit against BASM alleged that the firm recruited physicians to refer their patients for out-of-network procedures at overblown prices and billed Aetna millions of dollars fraudulently. While stories like this are responsible


for the negative press that out-of-network procedures receive, there are times when an ASC should consider going out-of- network, ASC professionals say.


When to Go Out-of-Network “Out-of-network arrangements work when providers adhere to reasonable fee schedules,” says Lisa Austin, RN, CASC,


12 ASC FOCUS AUGUST 2016


When the fees get ridiculously low, you might consider going out-of-network. That’s the driving force.”


— Maggie Summerfelt Advanced Surgery Center LLC


vice president of facility development at Pinnacle III in Lakewood, Colorado. “When a payer does not offer reasonable reimbursement rates to your ASC, or if the payer indicates it has enough provid- ers in your market, you might want to consider going out-of-network.”


Advanced Surgery Center LLC in Omaha, Nebraska, performs out-of- network procedures with a few com- panies only, says Maggie Summer- felt, administrator. “When the fees get ridiculously low, you might con- sider going out-of-network. That’s the driving force,” she says. “You have to negotiate, but sometimes payers will want to pay less than Medicare. We had an insurance company that was paying us less than Medicare. Fortu- nately, our physicians have enough market share, so that insurance com- pany came around. ASCs can save the payers a lot of money, we are cheaper than the hospital any day, and the payer understood that and came around.” When a new facility opens and attempts to obtain a contract with a payer that has a closed network, either due to a narrow network or market saturation, the facility might consider going out-of-net- work, says Dan Connolly, vice president of payer relations and contracting at Pin-


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