To be in-network or not to be?  This is a question for which many behavioral healthcare facilities struggle to find an answer.  There are so many things to consider before signing any contract, but it can be difficult to know what those things are.  Ultimately, it comes down to the choice of the facility decision-makers, but there are a few things to consider during the process of making a decision.

First, what does being in-network mean?  It means that your facility enters into a contract with an insurance company.  Each contract for each payer will outline different things but typically, the contract will include agreements for what services you will offer and for what price. For BCBS plans, the contract includes payments being sent to your facility, instead of sending them to the member.

Knowing the pros and cons should be the first step in making a decision.  Here are some important topics to consider.

Top 3 Pros of being an in-network provider:

1. BCBS payments will be sent directly to your facility, instead of to the member.  This is huge for most organizations as it means that less manpower can be spent on tracking down the payments from the members.  Sometimes, this can be an actual full-time job and can even require hiring a collection agency which can be expensive. A steady stream of revenue is always a necessity for keeping your doors open.

2. Insurance company referrals.  Once you are in the network of the payer, your facility will be listed in the payer’s network which means they will refer patients to receive treatment from you.  Referrals can be a vital piece of the puzzle, especially for a new facility who is just opening their doors. Referrals can sometimes even reduce the amount of money that is spent on marketing and advertising, which can be a huge chunk of change!

3. Contracted rates take the guesswork out of expected revenue.  Being able to forecast your revenue stream can be essential to remaining successful in the long-term.  It also allows your organization to provide potential clients and their families with a comprehensive cost estimator for the treatment provided by your organization. Part of the process of going in network is negotiating rates with the insurance company.  Each of the services you provide will go through the negotiation process until you reach an agreement. Being able to predict the reimbursement you will receive for each client’s treatment stay definitely has its advantages.

Top 3 Cons of being in-network:

1. Negotiated reimbursement rates can be much lower than you’d think.  An out of network provider has the freedom of deciding what to charge for services.  Being in network means that you can only bill for the rate that is negotiated. In my experience, the rates insurance companies offer during the negotiation process are much lower than out of network reimbursement rates.  Sometimes startlingly so.

2. Contracting with an insurance company usually means no extras.  There are two types of services a behavioral healthcare facility normally offers; the core treatment program and the “extras”.  The “extras” are typically called ancillary services which are the services provided beyond the core program such as family sessions or case management services.  Insurance companies typically expect that those services will be included with the overall negotiated rate, so you would no longer be able to bill for those services.

3. Tracking down those BCBS payments.  This is the most obvious downside to remaining out of network.  The process of collecting checks from the members can be expensive and time consuming.  

There are other points to consider, of course, aside from the top three mentioned above.  Some payers require the individual provider also sign a contract, which means the provider rendering services at your facility should be included in your discussions as some providers don’t want to be stuck in a contract.  Patient deductibles and coinsurance amounts are typically lower when they see a provider in the payer network. Collecting less money from the patient up front is very important to some facilities. Sure, referrals are great.  But, at the cost of less reimbursement?

All things considered, it really comes down to what is important to your facility and your individual provider. These points should be discussed thoroughly and considered carefully prior to entering into a contract with an insurance company.   

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