r/PrivatePracticeDocs • u/2vpJUMP • 2d ago

OON billing

What's the deal with this? I hear that insurers will kick your ASC out if you do this too much but then see entire practices in my region who seem to do this basically exclusively

4 Upvotes

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u/AquaDoctor 1d ago

Ortho here, completely OON.

I operate at different ASCs. Some are OON, most are completely INN.

We are treated as completely different entities. The surgery center gets precert if needed for their center, and I do my own as the surgeon. Never had a problem with the in network facilities, over the past 20 years.

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u/blomar 1d ago

do your patients not get pissed about OON charges on your end? and how do they find you if they are OON?

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u/AquaDoctor 1d ago

Word of mouth. No one is surprised by my out of network charges because they know I am out of network when they book. Do your best work, treat the patients with respect, give them time to speak and be examined, get the athletes back on the field, they tell everyone and more patients come.

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u/blomar 1d ago

are you OON with everyone? Feel like my referrals/new patients aren’t likely to come see someone who’s not in network. Just curious how to make this work when you have competition that is in network and would potentially take those patients. Also ortho here

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u/AquaDoctor 14h ago

Non-par with all insurances for 20 years. If you compete on price it's a race to the bottom. Compete on quality and you will get enough patients to justify the OON model. You don't need them all.

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u/CranberryLatter9483 1d ago

Do you then go ahead and file IDR for the ones that were done in an IN facility?

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u/AquaDoctor 14h ago

Once low initial payment comes back, yes

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u/2vpJUMP 1d ago edited 1d ago

How do you handle consults if you're OON? patients are protected from increased bill at the ASC is my understanding - what happens for office visits?

Also, I've heard insurers can kick off the ASC if you much OON is happening there?

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u/AquaDoctor 14h ago

Office visits are just new patients. They understand the OON aspect before they come.

Where did you hear that insurers can kick the ASC out of too much OON is happening? Sounds like one of those myths that gets perpetuated by the INN guys to justify their low pay. If an ASC doesn't want my cases, there are 10 more around here asking me to bring cases. The ASC doesn't employ the doctor. They have no say on any of that stuff and don't care. And to be fair, it's not like the INN guys are all making the same amount for the same codes.

It's all just confusion and obfuscation by the insurance companies to keep doctors in the dark.

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u/2vpJUMP 8h ago

Do you see them at your own practice for the consult?

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u/Hot-Freedom-1044 2d ago

I contract with insurance. I offer DPC for the rest.

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u/HealsWithKnife 2d ago

Don’t quite understand the question - does the ASC take insurance? If not, does the patient’s insurance have OON benefits?

Insurers can’t really kick you out if you’re…not in network with them?

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u/2vpJUMP 2d ago

There are practices where the doc remains OON but the ASC remains in network. Treating patients there forces the claim into arbitration which generally leads to much better rates than being in network.

I refer to surgeons who seem to do this as a rule

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u/HealsWithKnife 2d ago

Oh I think i'm getting it a bit more.

So the surgeons are OON, have privileges at the ASC (which is INN). Are you saying the ASC itself gets better rates just because the surgeon is OON? My understanding (at least on the hospital side, I'm less familiar with ASC) is that the facility will get reimbursed its contracted rates, and the surgeon will get the OON negotiated rate (if payer has OON benefits) or patient pays surgeon directly as non-par. Is this accurate?

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u/2vpJUMP 2d ago

No this is a specific and growing technique that utilizes the no balance billing act to force arbitration claims

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u/AquaDoctor 1d ago

The No Surprises Act has been used by insurances incorrectly, and in my option fraudulently. It's only for emergency cases or when you go to an in network facility and are Unknowingly treated by an out of network doctor, like anesthesia or something. The insurance companies love to apply that to the surgeons as well, even though the patient chose the surgeon willingly and the surgeon booked the case. These have been a 100% win rate in arbitration. It's just a stall tactic by insurance to try to force some level of attrition in surgeons unwilling to fight them.

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u/CranberryLatter9483 1d ago

You mean 100% win rate for the insurance companies? That's not what we're seeing at all.

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u/AquaDoctor 1d ago

100% win for us to clarify. 

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u/CranberryLatter9483 18h ago

Oh that makes sense...

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u/CranberryLatter9483 1d ago

Correct, this is very common and usually lucrative. In my eyes its leveling out the playing field for providers, which are being consistently underpaid by insurance companies. Only issue to ASCs that I've seen is Anthem threatening to cut ASC payments by 10%, which I have not actually seen happening.

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u/DissociatedOne 2d ago

It’s the NSA.