Out-Of-Network Vs. In-Network Strategies

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The Out-of-Network VS. In-Network world in healthcare is changing
Source: Wakefield
June 12, 2024

It’s No Longer Black & White

The Out-of-Network VS. In-Network world in healthcare is changing, and some providers are no longer finding a single approach works to maximizing their bottom line. Finding the right mix of in and out-of-network strategy can allow providers to find the sweet spot of reimbursement.   

Sometimes this means that providers leave contracts that are no longer serving them well.    This could be simply an agreement where the rates are no longer covering costs, or the requirements of the contract make it unnecessarily burdensome from an administrative perspective to operate your business. If a payer refuses to come to the table and reach an agreement that allows you to serve your patients it may be time to ditch the contract and provide your care in the Out-of-Network strategy.

Conversely, there are times that the out of network approach either does not make sense or is not possible.

Many governmental payers for example do not offer an out of network reimbursement method, so in order to serve that patient population the provider must enter into an agreement.  

However, there are times where payers do offer reimbursement for out of network providers but with limitations to how that reimbursement is obtained.

For example, a payer may offer reimbursement for an out of network procedure but do so by paying the patient directly.

Depending on the providers patient relationships this may be a perfectly acceptable solution.  The trouble can be for those providers who have limited relationships with the patients that they serve. Collecting money from a patient often times comes with additional complications. Patients who have received checks from their insurance companies may not fully understand that this reimbursement is for the services you provided, and they may not understand the ramifications of them holding on to that cash.

For providers with a more limited patient relationship lifecycle, it may make financial sense to engage in some in network activities to save the money spent chasing patients for their reimbursement. 

When a provider has a mix of in and out of network payers it is even more important to handle their entire receivable under one vendor partner, the strategy is complex enough and should not be complicated by management of multiple vendors with separate reporting. Finding a partner who excels in billing everything from Medicare to your most complex out of network payer is not easy, but we ready to show you how we do it!