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O U T P A T I E N T S U R G E R Y M A G A Z I N E O N L I N E | A P R I L 2 0 1 5
Thinking About Going Out-of-Network?
Larger reimbursements are yours for the taking, but at what costs?
W
ith tales of
$80,000 knee
arthroscopies
and $40,000 gallbladder
removals, out-of-network
billing has a less-than-stel-
lar reputation. But some
say it represents an
opportunity for many sur-
gery centers and hospitals
to improve profitability.
"You can generate higher
— and frequently much
higher — payments by
being out-of-network,"
says John Bartos, CEO of
Collect Rx, a company
that maximizes reim-
bursements on out-of-network bills.
Volume-discount relationship
Network providers have agreed to accept the negotiated health-plan
price as payment in full. Mr. Bartos says that being in-network works as
a "volume-discount relationship," where insurance companies refer
patients to providers in exchange for a contract with low reimburse-
ments. For smaller centers and individual providers, companies usually
hold the power over these contracts, he says.
"One of the issues that we came across was that insurance compa-
C O D I N G & B I L L I N G
Kendal Gapinski
z OUT-OF-NETWORK Douglas Won, MD,
speaks to a patient at his facility in Dallas,
Texas. Dr. Won is an out-of-network provider.
In-Network Out-of-Network
Patient's insurance 90% of in-network costs 70% of out-of-network costs
Contracted fee
$2,000 for
knee arthroscopy
$6,000 for
knee arthroscopy
Reimbursement
$1,800
(90% of $2,000)
$4,200
(70% of $6,000)
How Out-of-Network Works
