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Difficult Airways - April 2015 - Outpatient Surgery Magazine

Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.

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3 5 A P R I L 2 0 1 5 | O U T P AT 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 nies were getting way too big and powerful," says Douglas Won, MD, founder and director of Minimally Invasive SpineCARE and Star Medical Center in Dallas, Texas. The Star Medical Center is complete- ly out-of-network; SpineCARE has both in- and out-of-network providers. "They give you a contract and you either take it or you don't. The cost of doing business keeps on rising, but the reimburse- ments are getting lower." Here's a very basic example of how being out-of-network can increase reimbursements. A patient coming in for a knee procedure has insur- ance that pays for 90% of in-network costs, and 70% of out-of-network costs. You're in-network with that insurer and have a contract to charge a $2,000 fee for the procedure, but your pricing for the surgery without a contract is $6,000. If you're in-network with that patient's insurance, you'll receive a reimbursement of $1,800 (90% of $2,000), whereas if you're out-of-network you'd get $4,200 (70% of $6,000). Some think these increased reimbursements come at the cost of los- ing patients. Not always true, says Mr. Bartos. "It's important to remem- ber that ASCs get their patients from physician referrals and not insur- ance companies," he says. Dr. Won says that he did see a few fewer patients, but that his finances improved when he went out-of-network. Most of the time the patient is on the hook for remaining charges. In the example above, the patient would owe the remaining $1,800 if out- of-network, but in-network he may have only had to pay $200. These charges could be even higher if he hadn't met his deductible yet. There are different ways to combat this. You can charge patients as if they're in-network, although usually state laws require you to inform pay- ors that you plan to do so. Or you can not actively pursue co-pays or deductibles and tell patients you'll collect what you can from their insur- ance, says Mark Manigan, JD, of Brach Eichler in Roseland, N.J. That, though, can land a facility in legal trouble, as some say it misrepresents a

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