Out-of-network doctors could see a decrease in income

Jan. 31, 2023

Out-of-network (OON) status has been financially advantageous for doctors who could not get reasonable in-network reimbursement rates with insurers. But in recent years, insurers have been making it harder to be OON, according to physicians and billing consultants familiar with this approach.

"It has become increasingly difficult for physicians to be out of network, and I believe that [being] out of network will eventually have to go away," said David J. Zetter, a business management consultant for physicians in Mechanicsburg, Pennsylvania. 

Consultants said OON doctors have to do more paperwork, such as obtaining prior authorizations. In addition, reimbursement rates are lower, payments are delayed, and they encounter more difficulties appealing plan decisions. Plans now use the No Surprises Act (meant to protect patients from unexpected OON bills) to support their OON clampdown. 

This trend affects many physicians. Zetter said some doctors purposely stay OON for all plans, while many become OON by default when they refuse to sign up with a plan, usually because of low rates. Many insurers, especially smaller ones that offer low rates, may sign up only a small minority of physicians. A 2017 study found that 21% of plans in the insurance marketplaces under the Affordable Care Act (ACA) had signed up less than one-quarter of available providers. 

As a result, many doctors who remained OON are abandoning that approach, said Zetter. He reported that doctor-clients who have been OON for years are now going in-network. "One of them is a neurologist who has been out of network for 15 years," Zetter said. "He doesn't want to deal with all the hassles of being out of network anymore." 

Zetter also predicts that plans' OON clampdown may force more self-employed physicians into employment. But he warned that employed physicians are not protected from the financial problems affecting self-employed physicians. "Employed physicians' salaries are pegged to reimbursement rates for self-employed doctors," he said. 

The tougher stance on OON providers can heighten feelings of burnout, said Gary Price, MD, president of the Physicians Foundation, an advocacy organization for physicians. "The paperwork takes a toll on physicians, as well as their staff," he added. "It's tremendously frustrating for staff who deal with it day in and day out." 

Medscape release

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