Inside A Practice

Doctors: Getting Paid for Out-of-Network Patients Difficult

By Franklin J. Rooks Jr., PT, MBA, Esq.

Many physicians have come to the conclusion that some insurance contracts aren’t worth having.  More and more physician specialties have opted out of participating provider contracts or have chosen not to participate in the first place.  Reimbursement is the primary reason for not participating.  The amount allowed for various CPT codes simply is not enough.  On top of that, there is the “MPPR” – Multiple Procedure Payment Reduction.  This ominous concept was crafted by the Centers for Medicare & Medicaid Services (CMS).

The MPPR functions to reduce the allowable amount of multiple medical procedures that are performed during the same session by the same provider.[1]  Insurance carriers, such as United Healthcare have modeled their reimbursement on this CMS policy, and implemented their own versions of the MPPR.[2]  Often, in-network reimbursement is not commensurate with the education, skill, and value that the physician delivers.

Under a provider agreement with the insurance carrier, the physician is bound by its terms, including nuances such as the MPPR.  The provider agreement requires the physician to accept pre-negotiated payments for specified services as payment in full.  When a contract exists with the insurer, the physician is referred to as a “participating provider.”  One legal definition of a participating provider is “[o]ne who agrees in writing to render health care services to or for persons covered by a contract or contracts issued by a health service corporation in return for which the health service corporation agrees to make payment directly to the participating provider.”[3]   Physicians who are not contracted with a particular insurance carrier are referred to as “non-participating” physicians.  Unlike participating providers, these non-participating physicians do not agree to accept the insurer’s reimbursement (and approved amounts) as payment in full.  Out-of-network providers are subject to a different reimbursement structure.




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