December 9, 2014


I am in-network with most plans at my office, but was approached by another doctor to join him in a venture where we will bill services out of network out of a new practice we are forming.  Is this okay?

Dr. K


Sounds like a potential case of "cherry picking", and will most likely not be a kosher arrangement.  Your relationship with carriers as an in-network provider is a contractual one, and depending on the terms of the contracts, you may be bound to accept in-network rates and provide services to that carrier's insureds for the agreed-upon fee schedule regardless of the entity you are operating out of.  Such are the contractual restrictions placed on many practitioners.  However, should your contractual in-network arrangements reflect a commitment for a specific tax ID number,and not extend to you individually, you may be entitled to charge on an out of network basis at the new practice.  So, the answer is, without seeing your participating provider contracts, I cannot give a definitive opinion.  

Happy to review.  My advice, do the required due diligence before proceeding with the proposed arrangement. 

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