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are out-of-network. Some ASCs have billed more in the past to out-of-net- work patients, but we charge everybody the same. We accept what the insurance company says is ‘usual and customary.’ We have never had any trouble accept- ing what is ‘usual and customary.’” You have to be careful with co-pays and deductibles and ensure the patient has out-of-network coverage as there are some plans that don’t allow for any out-of-network benefits, Connolly says. In addition, you must be careful when performing out-of-network procedures. “In Colorado, laws govern the waiving of co-pays and deductibles,” he says. “If you are routinely waiving the portion the payer has determined is the patient’s responsibility, you could be in significant trouble.” Payers can make it difficult for providers to secure an in-network

contract if a provider does out-of- network cases frequently, he adds. “I have seen payers refuse to extend in-network contracts to ASCs because those ASCs performed a significant number of cases out-of-network. If you perform procedures out-of-network, the payers may not be open to you ‘switching’ sides. “This is why we do not look at being out-of-network as a long-term sustainable strategy,” Connolly says.

Proceed With Caution In this age of price transparency, it is best to get a legal review of the state-specific statutes, regulations, attorney general opinions, case laws, etc., when consider- ing going out-of-network, Connolly says. “Your attorney will advise you on how to disclose prices to patients and minimize adverse effects of going out-of-network.”

It is also important to make sure that

your ASC has good cash flow or a good line of credit when considering out-of- network procedures because a payer takes longer to pay for those, Summerfelt says. “It takes about twice as long to get paid,” she says. “We take about 30–60 days with in-network payments and about 120 days for out-of-network payments. In some cases, it is beneficial for us to wait 120 days.”

A good biller also is a necessity for going out-of-network, she adds, and that biller would have to understand out-of-network billing very well. Austin advises ASCs to “know

all your options, communicate with your payers, and inform your patients before going out-of-network. Those are your most important


considerations because our number one priority is patient care.”


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