Out of Network Blues

Did you know that most state and federally regulated insurance plans have an “all in” or “all out” clause?   If the doctor owner is out of network yet hires an associate who wants to sign up for a PPO the payer may insist that the owner doctor must be part of the network too.

Or if a doctor wants to open a new PPO practice in a nearby town and keep his status of fee-for-service in the original location, he/she better check the contract.  Some or all the providers may have an “all in” or “all out” clause that would apply to both locations.

Are Predeterminations Still Advised?

That depends on the services to be provided and if coverage and benefits have been verified as accurate.  Replacing missing teeth?  Crowns or other prosthetics need replacement? Pre-de is a promising idea. There has been a shift towards predeterminations due to faster turnaround from technological advances.  A predetermination will indicate whether the procedure is considered a covered benefit, the contracted fee and the estimated patient coinsurance responsibility (based on claims filed or processed at the time the pre-de is filed).   The patient must be told that even though the predetermination indicates there is coverage, the insurance payer can still deny payment or reduce payment.   Look for the fine print on the pre-de that states: “This determination is not a guarantee of payment for the services provided.”


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