Featuring: Brad Gingerich | Vice President, Payor Strategy
Considering the decision to go out of network with a payor? Understanding the implications and implementing a well-thought-out strategy is crucial. Discover how to navigate the process of debating going out of network effectively to optimize your healthcare organization’s financial stability and patient care.
Why Consider Going Out of Network?
One common reason for health systems to exit a payor’s network is the inability to reach mutually agreed-upon reimbursement rates and terms during contract negotiations. Years of challenges with timeliness, accuracy and costs of pursuing full reimbursement from an insurance company often lead to this last-ditch effort.
Impact on Providers
Two of our clients recently leveraged an out-of-network strategy that ultimately resulted in contract rates double the standard annual increase of 2%-3% for each year of their agreement. One of the organizations only went out of network for a matter of hours before settling on a higher rate with the payor. The other merely threatened to exit the network, leveraging social media and community news outlets to make their position public and put pressure on the payor to come to the table with more reasonable rates.
Impact on Payors
The impact of going out of network varies based on the size of the health system. It can challenge network adequacy for government-sponsored plans, disrupt network access for commercial patients and their sponsoring employers and increase payment for out-of-network services.
Tips for Considering + Implementing an Out-of-Network Strategy With Major Payors
Assess Current + Prospective Out-of-Network Patient Volume
Review patient volume metrics such as primary care attribution by plan type, elective procedures by plan type and patient referral patterns. If the emergency department is a primary access point for patients, the non-participating status will have a lesser impact to patient volume since all emergency services qualify for in-network benefits regardless of participation status.
Be Selective About In-Network Services
Consider keeping primary care, OB/GYN and pediatricians in-network to maintain HMO patient attribution. This is especially important for temporary out-of-network periods. It also mitigates disruption of PPO member attribution to the primary care physicians, allowing patients with out-of-network benefits to still be referred to the out-of-network facility for elective procedures.
Educate Physicians About the Out-of-Network Experience
Reassure primary care physicians and staff about the implications of being out of network and its impact on access to care. Provide a clear roadmap of expectations and reinforce the need to have privileges at a participating facility.
Connect With Impacted Self-Funded Employers
Rank and engage the top 10 self-funded employers utilizing the out-of-network plan. Consider offering direct-to-employer network rates or alternative insurance carriers. Consider petitioning the payor for renegotiation to restore your organization to the network.
Keep Patients Informed + Engaged
Educate patients about the implications of being out of network for each service and plan type, including the distinctions between medical emergencies and elective procedures, whether they have secondary coverage and different plan types. Utilize existing communication channels such as patient portals and targeted outreach via mail or phone. Ensure staff are available and equipped to address specific patient questions through a centralized call center.
Make Your Position Public
As payor/provider contract negotiations become more public, consider sharing your stance with community media outlets to shed light on your position. Clearly state your position and support it with available data to demonstrate the gap between reimbursement and cost, supporting your rationale for a higher negotiated rate.
Prepare Your Operators for a Smooth Transition
Ensure your Patient Access team is prepared to accurately schedule and register patients and answer coverage-related questions. Update processes and tools to identify at-risk accounts and ensure compliance with the No Surprises Act and any applicable state surprise billing laws. Evaluate utilization management procedures as well as billing and collections processes to effectively manage out-of-network claims.
In Summary
When healthcare organizations consider the decision to go out of network with a payor, it requires careful analysis and planning.
Whether it’s a temporary tactic to strengthen negotiations or a permanent decision, assessing patient volume, providing comprehensive education to staff and patients, and engaging employers are critical components for a smooth transition. By proactively managing these factors, organizations can navigate this shift successfully to strengthen financial performance and continue delivering high-quality care to their communities.
Ensemble Health Partners offers comprehensive revenue cycle managed services to clients, including strategic guidance for health system executives and managed care departments to improve payor relationships. We support our clients with out-of-network strategy analysis and operationalization. Our payor strategy experts have more than 15 years of experience leading payor negotiations, educating managed care teams and effectively addressing and resolving payor challenges.
Brad Gingerich has 16 years of experience in managed care and revenue cycle operations, designing and implementing national payor strategies for large health systems.
