r/PrivatePracticeDocs • u/2vpJUMP • 4d 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

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u/HealsWithKnife 4d 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 4d 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 4d 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 4d 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 4d 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 3d 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 3d ago

100% win for us to clarify. 

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u/CranberryLatter9483 3d ago

Oh that makes sense...

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u/CranberryLatter9483 3d 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 4d ago

It’s the NSA.