Hi Dr. Centore,

I’ve found your blog incredibly helpful in getting my practice off the ground. I’m looking at getting out off of an insurance panel and taking out of network reimbursement.

I keep hearing different things and not sure what’s legal or potentially puts me at liability. I know that I can always bill a patient the fee, and they can be reimbursed what the insurance covers. However, I know some of my colleagues arrange it to where the therapist takes the full insurance reimbursement directly, but negotiates the patient responsibility, so that the patient ends up often paying less than the insurance deems is the amount they’re responsible for.

So, for example, an insurance plan pays 60% of the usual customary rate (let’s say the UCR is $150). So therapist X gets paid $90 from insurance, and the patient is responsible for $60. Let’s say they can’t pay that, so they negotiate to pay $40.

Is that allowed? I’ve read how insurance companies are beginning to sue providers (typically larger clinics) for such practices.

Any guidance on this is appreciated!

Best,

Lila, Ph.D

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Greetings Lila,

For in network providers, while insurance contracts can vary, generally the provider is contracted to accept the clients / patient’s copay and is not permitted to waive or reduce the patient responsibility portion.

For providers who are out of network, you probably have a lot more choice here. Out of network providers typically bill the client / patient their full rate, and then the client / patient seeks whatever reimbursement insurance might pay.

I hope this helps!

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