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Topic: Dos and don'ts for out-of-network billing

Ambulatory Surgery Reimbursement Update, September 2, 2008

Consider the following dos and don’ts from Joshua M. Kaye, Esq., and Jerry J. Sokol, Esq., partners at McDermott Will & Emery, LLP, in Miami, when you consider exercising an out-of-network billing strategy:

• Don’t have an unspoken agreement with patients that you will allow them to disregard their copay bills. If the preferred provider organization or insurance company knew you were generally waiving the copays instead of collecting the remaining 30%–40%, they would most likely argue that the billed charges should be 30%–40% lower, Kaye says.
• Do take meaningful steps to collect from patients if you’re taking the position that you’re not waiving copays.
• Don’t routinely waive copays without thorough analysis of current state laws.
• Do create a compliance policy that addresses waivers of copays and clarifies what kinds of situations may warrant waivers (e.g., a patient’s extreme economic circumstances).
• Don’t overvalue your out-of-network profits when contemplating a potential ASC sale. Consider the business side of an out-of-network billing strategy and how an out-of-network approach will affect the likelihood of your ability to sell the surgery center in the future.

For more information on out-of-network billing, see the August issue of Ambulatory Surgery Coding and Reimbursement Insider.

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