PRIVATE PRACTICE - AC24 - Navigating Out of Network Billing and Practice Issues
Since 2013, inflation has risen by over 32%. This means what took $1.00 to purchase an item in 2013 now takes $1.32 to purchase the same item in 2024. Unfortunately, insurance reimbursement has not risen 32% over the same 11-year period. In fact, considering inflation, you are actually being paid less in 2024 than you were in 2013, yet your expenses, especially health insurance, have increased drastically. For example, the Medicare conversion factor has decreased 9% since 2018.
This inverse relationship between reimbursement and cost to run a practice is fueling the trend for providers to go out of network (OON). But what does being out of network mean for your billing practices? Many providers go out of network only to continue running their practice as if they were in-network – writing off denied and unpaid claims, accepting arbitrary reimbursement cuts, and failing to balance bill patients. Providers must change their mindset and business practices to have a successful OON practice.
This session will discuss considerations for going out of network, including whether you can have some therapists stay in-network while others are out of network, the pros and cons of accepting or not accepting assignment, and how to balance bill patients and carriers for OON claims. In addition, the session will teach participants what they must still do each visit regarding documentation and billing even though they have no contractual relationship with the insurance carrier. The session will discuss being out-of-network with Medicare Advantage (MA) plans and financial limitations.
Learning Objectives:
Upon completion of this course, you will be able to
- Provide a method for decision-making when analyzing whether to go out of network with commercial carriers and Medicare Advantage Plans.
- Discuss the pros and cons of accepting assignment on out of network claims.
- Outline the differences in how in-network and out of network claims are (and should be) managed depending on whether the provider accepts assignment or not.
- Discuss prompt pay discounts, balance billing patients and managing claims denials/payment reductions.
- Summarize what information an insurance carrier may or may not be able to share with you (and vice versa) if you have no contractual relationship with that insurance carrier
Rick Gawenda
PT
Gawenda Seminars and Consulting
RICK GAWENDA, PT, is a licensed physical therapist with over 30 years of experience and currently serves as the founder and President of Gawenda Seminars & Consulting, Inc. He graduated with a Bachelor of Science degree in Physical Therapy from Wayne State University in Detroit, Michigan, in 1991.
He has provided valuable education and consulting to hospitals, private practices, skilled nursing facilities, and rehabilitation agencies in the areas of CPT coding, ICD-10 coding, billing, documentation compliance, revenue enhancement, practice management, and denial management as they relate to outpatient therapy services. Mr. Gawenda has presented nationally since 2004 and has provided over 1000 on-site seminars and webinars.
In addition, Mr. Gawenda is retained by attorneys to serve as an expert in regard to legal or physical therapy state board issues regarding documentation, billing, supervision, and utilization of support personnel and compliance with insurance rules and regulations as well as physical therapy state board requirements.
Mr. Gawenda is a member of the American Physical Therapy Association (APTA) and Michigan Physical Therapy Association (MPTA). Mr. Gawenda is a Past President of the Section on Health Policy & Administration of the APTA. He is the current Chair of the APTA Private Practice Payment Policy
Mr. Gawenda is also the author of “The How-To Manual for Rehab Documentation: A Complete Guide to Increasing Reimbursement and Reducing Denials” and “Coding and Billing for Outpatient Rehab Made Easy: Proper Use of CPT Codes, ICD-9 Codes, and Modifiers”.
Gwen Simons
Esq, PT, OCS, FAAOMPT
Simons & Associates Law, P.A.
Gwen Simons, Esq, PT, OCS, FAAOMPT is a healthcare lawyer at Simons & Associates Law in Scarborough, Maine. Her law firm caters to the needs of health care providers in private practice, representing providers in contract negotiations/disputes with payers and providing Medicare/HIPAA compliance and practice management consultation. She’s also been a fearless advocate for physical therapy issues, taking on the Goliath insurance carriers on prior authorization, payment, unfair contracting issues in Maine’s state legislature as the Maine Chapter APTA’s lobbyist. She has served on several PPS and AOPT Task forces on payment issues and is the 2023 recipient of the Maine Chapter’s President’s Service Award for her advocacy work to pass Maine legislation to prohibit insurance carrier prior authorization requirements before visit 12.
Course Instructions
- Click on the Contents tab to watch the course recording.
- Click the Take Quiz button to complete the assessment. Learners will have 3 attempts to pass and must answer at least 70% of questions correctly.
- Click Fill Out Survey under the Evaluation listing to provide valuable course feedback. Scroll down on all questions as there may be answer options that expand past the size of the window.
- Click the View/Print Your Certificate button under the Certificate listing. You can view/print your certificate at any time by visiting the APTA Learning Center and clicking the CEU Certificate/Transcript link on the left-hand side of the page.
Need Assistance?
For assistance logging in, accessing activities, claiming credit, or for other questions or concerns, please e-mail learningcenter@apta.org.
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