Audit Risks Growing for Out-of-Network Providers

Dr. R. A. Foxworth, FICC, MCS-P

With audits on the rise, more and more providers tell me they plan to go out-of-network with insurance companies to reduce their risk. If only it were that easy. The rules for billing, coding, and documentation are the same whether you are in-network or out-of-network. Additionally, you lose some of the benefits of being an in-network provider, such as more patient referrals, more timely payments, and lower costs to patients. As an out-of-network provider, in a few cases, you may receive higher reimbursements, but with that comes increased claim scrutiny and a higher cost to the patient. And, in other cases, there are NO out of network benefits, yet there are still potential risks involved since the patient has a contractual agreement with a health plan.

Many believe that by not participating as an in-network provider, they are exempt from post-payment audits. This couldn’t be further from the truth. With any payer, you are subject to records requests and audits of your billing, coding, documentation, and collections. Also, out-of-network providers are required to “balance bill” their patients. That means you are responsible for collecting the difference between your charges and the amount paid by the payer. Not doing so can be considered a crime, with criminal and civil penalties. Many states even have laws regarding balance billing. For example, Florida Statute §817.234 (7)(a) states:

It shall constitute a material omission and insurance fraud, punishable as provided in subsection (11), for any service provider, other than a hospital, to engage in a general business practice of billing amounts as its usual and customary charge, if such provider has agreed with the insured or intends to waive deductibles or copayments, or does not for any other reason intend to collect the total amount of such charge.

Under no circumstances am I suggesting that you should participate in every health plan. In fact, I encourage providers to review their agreements annually and make sure that being a participating provider still makes sense for your practice. In some cases, you may find that your cost of doing business is $45 a visit, in which case, becoming, or remaining, a participating provider in a plan that pays you $35 a visit, may be a bad business decision.

As a ChiroHealthUSA participating provider, you have already taken the necessary steps to become more competitive with in-network plans. In fact, you could also be reducing potential risks from the fallout of balance billing your patients when they choose to opt-out of using their insurance and choose instead to use ChiroHealthUSA. By opting out of their insurance, the patient agrees to self-pay and has stated that they do not want you to submit any claims to the insurance company. The patient is then only responsible for charges under the ChiroHealthUSA fee schedule.

Whether you choose to be an in-network or out-of-network provider, make sure that your decision makes good sense for your business. You also want to be sure that you and your team are conducting a financial report-of-findings with all your patients. This is the best way to ensure that you and your patients are on the same page when it comes to their financial responsibility. Let your patients know from the beginning what their insurance will cover, what their responsibility may be, and give them affordable options for payment. This will go a long way to improve patient retention, increase revenue, and increase your patient visit average. To learn more about how patients can opt out of insurance or to download our FREE Patient Election to Self-Pay Form, click here.