Wiki Trying to get out-of-network

[Rsfoster55]

We have a a group in Georgia with 2 doctors. The group and both doctors are in network with Anthem/BCBS. One of the doctors would like to be out of network and the other doctor would like to stay in network. Any help would be appreciated. What steps do I need to take in order to start this process and how does this effect billing when we submit the claims. Do I still bill under the group or just the doctor?

 

[csperoni]

Step 1 is to check your contract. Some insurances require all physicians in the group to be participating. If this insurance does permit it, the contract will typically specify how much notice you must give. You would typically submit in writing of your intent to become out of network and what that effective date will be. Any current patients with BCBS should be informed of this change. Any new patients seeing the out of network doctor must also be properly informed.
I'm not stating it's impossible. If the insurance contract does permit it, there is administrative work required to ensure your patients are made aware of their financial responsibility.
Even in a group, claims are always submitted with the physician's name and NPI who rendered the service. Unless you are planning on actually splitting the group and having separate TID.
I would also want to find out why one of the doctors wants to withdraw. Why do they not want to see any BCBS patients any longer? Are they reducing work? Planning on retiring soon? Hate the red tape or hoops to jump through? Believe the fee schedule is not equitable?