July 1, 2011



In reference to yesterday's discussion, it is clear that when I had not signed any contract with insurers and was not an in-network provider, many years ago I had an employed physician who was in-network and Aetna then paid every MD in our practice in-network rates. They certainly agreed after a couple of years that they were in the wrong, but it took many discussions with ignorant staff members in the insurance company and many, many hours of billers’ time was clocked in working this out. After about three years, we had to cut our losses, only received 70% of what we were due and had to move on. So a practice may do everything correctly but be hurt financially by the third party.

Dr. S


Provided by Anne M. Dunne, RN-BC, Director of Healthcare Consulting at Grassi & Co. -

Jennifer’s response is absolutely correct. Once you are a credentialed and approved provider, you will be paid a participating provider rate depending on the agreement signed by each practice. In my experience, if a practice is contracted as participating, the provider will be paid the in-net work rate regardless of their participation status.

In deciding whether or not to become a participating provider, consider the following: Review the fee schedule for participating providers and compare against your private fee schedule and usual/customary charges. As a non-participating provider, you can elect to accept assignment or not accept assignment on a claim by claim basis. However, you can not bill the patient more than the limiting charge on non-assigned claims. Generally, the approved amount for non participating providers is approximately 5-10 percent less than participating providers. Most importantly, the beneficiary receives payment on all non-assigned claims. A provider must factor in the labor costs associated with following up on the claim, obtaining the insurance payment from the patient and balance billing the patient. A practice with strong revenue cycle management competencies may do well with a non-participating status. Those with limited billing/collection resources may do better becoming a participating provider, collecting the co-payment at the time of service and billing the payer for the contracted rate.

Anne M. Dunne, RN-BC, MBA
Director of Healthcare Consulting
Direct Dial: 516-336-2463
Cellular: 516-524-3771


Hi Jennifer-

In our experience your statements are absolutely true. We have also found is that some plans will allow a provider to vary their in-network vs. out of network (OON) participation based on TIN#. This allows a provider to work for different groups with varying in vs. OON circumstances and be attached to the respective TIN# of the group(s). Although not a common scenario we have experienced this with providers who work in neighboring states like NY, NJ and CT.


Alisa Rivera
Medical Management Corp of America
VIce President, Operations
(845) 363-4845


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