Expert Opinion
ASCs considering out-of-network pro- cedures might want to hire an expert to take advantage of the opportunities af- forded by out-of-network, says John Bar- tos, chief executive officer of Collect Rx in Rockville, Maryland. “There is an under- estimation of what it takes to be success- ful with out-of-network overall,” he says.
“When providers are looking at the landscape today on how to improve re- imbursements, there aren’t a lot of op- tions,” he says. “You can’t change the Medicare and Medicaid rates. Out-of- network is one of the only opportunities that offers flexibility in the area.”
For a facility that is 100 percent in-net- work and wondering how to go out-of-
nacle III. “Although rare, we have had a couple of payers decline to add new ASCs. And, as my colleague, Ms. Aus- tin, stated, another reason to go out-of- network is when payers offer very low or unreasonable rates.” Some payers won’t consider extending
an in-network contract to an ASC until the ASC is fully credentialed, Connolly says. It could take up to 8 or 9 months to get full credentials after a new facility opens. “There is a contractual gap during that time, which presents issues for providers and patients alike. While the facility is waiting for credentialing to be finalized with the payer, it may consider having patients remit payments based on in-network pricing.”
Disadvantages of Out-of-Network Insurance companies are doing every- thing in their power to make it diffi- cult for ASCs to provide, and patients to receive, out-of-network care, Connolly notes. “They may not allow out-of-net- work coverage for certain types of plan benefits or impose financial restrictions on coverage, such as extremely high deductibles,” he says. “Some have an out-of-network fee schedule that makes it cost-prohibitive for patients to be seen
network, Bartos recommends a “dip your toes in the water” approach. “Eval- uate various criteria to find the right pay- er to start with. Look at their contract, do an analysis of payer mix, determine who you are most reliant on, and where you see your rates being the best versus the lowest,” he says. “That way you miti- gate the risk by trying something new on a small scale. Don’t cancel your biggest payer contract if you are simply trying out out-of-network.”
You need to have the expertise and de- velop resources to be good at out-of- network strategies, Bartos says. “Think about whether you have the expertise, resources and data analytics to do out-
by an out-of-network provider. At times, they will send payment to the patient requiring the out-of-network ASC to obtain facility reimbursement directly from that patient. The system is essen- tially created for in-network services.” Health care providers receive the
benefit of payers channeling the flow of patients to them via these networks, he points out. In turn, by ensuring the bulk of services are provided in-network, payers achieve cost savings. “If an in-network physician brings an out-of-network patient to your ASC, the payer may penalize the physician,” he says. “The payer may also penalize the ASC for using an out-of- network surgeon.”
It is becoming increasingly apparent that patients are actively encouraged not to use out-of-network providers, Summerfelt says. “Even if we have con- tracts with payers like Blue Cross Blue Shield (BCBS) or Coventry, they have contracts with individual hospitals and patients are not as likely to come to our ASC out-of-network. As an example, BCBS has a tier system. There are three tiers and being at the first tier is the best and the patient has the least responsi- bility, 80–20; at tier 2, the patient has 60–40 and at tier 3, the patient is out-of-
of-network procedures. Do you have in- house help or should you get an outside vendor? If you decide on bringing on a vendor, consider working with them on a contingency basis.”
Going out-of-network has very little down side if an ASC has the expertise and is properly selective on who it is going out-of-network with, he says. “Conversely, if an ASC does not have the expertise and is not selective, that could quickly become a down side. Out- of-network is complicated and the con- stant back and forth with the vendors and payers could get tricky.
“Don’t jump in blind,” Bartos cautions ASCs. “Be smart and proceed wisely.”
network. The patient is still incentivized to see us but it gets harder.” With out-of-network procedures you
also don’t have a referral source, she says. “[What that means is] if the patient chooses where they would have their sur- gery, they are only looking at in-network lists because they know they will get a better deal. Now, if one of our physicians calls and tells me that he wants an out- of-network patient to come to us, we call the patient and explain how we are less expensive than hospitals, and that usu- ally works with the patient.” Patients also incur higher co-pays and deductibles when they utilize their insurance company’s out-of-network benefits, Austin says. “At our ASC, we tell the patients up front that they are out-of-network, as does the insurance company,” Summer- felt says. “We are transparent on both ends. The patients sign a statement that says they know we are out-of-network. We also state on our claim to the insur- ance company that we would not charge the patient more because they are out- of-network. For instance, if a patient pays 20 percent with in-network and 40 percent with out-of-network, we try to charge them 20 percent even if they
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