Yawn. The most BORING topic – yet one of the most important for medical providers. With thirteen plus years in medical accounting/patient billing, I know this is a commonly overlooked detail. Do you know all the payers with whom you are contracted? Do you know all the payers who pay you? How often is this reviewed? Do you have a standardized set of expectations for your payers in order to negotiate?
The payer negotiating and “credentialing” process a process that is LABORIOUS. Gathering paperwork, filling out forms, and negotiating is not how most professionals want to spend their time, unless of course they are attorneys or accountants ;) The process is meant for the payers to “vet” you and make sure you are legit. The process also allows you, as the provider, to align yourself with different employer groups or accountable health organizations for exposure/marketing of your practice.
Why are some networks so narrow? These networks are aiming for a truly patient centered experience. The primary care provider and the patient would make decisions together for the best course of treatment. As a specialist, you need to decide what groups might have the biggest impact on your bottom line. That is where the negotiating comes in. In a narrow network, the specialists need to prove their worth and may have to jump through extra hoops or trade in contract negotiations to become an in-network provider.
Is it so bad to be out of network? If you are out of network, most commercial insurance plans have an entirely separate (and large) deductible for out of network providers. While the insurance company may “allow” the full fee of your service instead of a negotiated discount that an in-network provider might receive – this balance typically falls on the patient. The patient becomes responsible for the entire balance. Large medical bills are extremely SCARY for patients. Scary may not even be the correct term – if they don’t know it is coming, they can be outright ANGRY.
Why can’t we all have set fee schedules and everyone just pay the fees we have?