In and Out of Network Billing for Providers

About Course

Format: On-Demand Webinar
Presenter: Kate Gilman, CPC, CPCO
Time: You can access the webinar anytime
Duration: 60 minutes
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Conference Materials (Password Required)
Deciding whether to be in-network or out-of-network with a payer can be tough and tricky for healthcare providers. In this webinar, we will focus on the differences between in-network versus out-of-network coverage and insurance requirements. We will also discuss the most common commercial and federal payers’ guidelines on out-of-network participation. We will go over Dos and Don’ts when billing patients with out-of-network benefits. Lastly, we will address some scenarios where it may be best to be out-of-network or in-network.

The goal of this webinar is to bring awareness to the rules for in-network vs out-of-network participation and billing requirements.

Learning Objective

  • Learn about in and out-of-network requirements.
  • Learn different payer stances and products for in and out-of-network.
  • Discover what it means to be out-of-network with federal plans.
  • Examples of in and out-of-network reimbursement.
  • Possible benefits of going out-of-network.
  • State regulations for out-of-network and balance billing.

Areas Covered in the Session:

  • In and Out-of-Network Requirements
  • Commercial Payer Out-of-Network Policies and Products
  • Federal Plans Requirements for Out-of-Network
  • What to do as being in and out-of-network
  • What is In-Network Billing
  • What is Out-of-Network Billing
  • Medicare Advantage & Medicaid MCO
  • Dos and don’ts about being Out-of-Network
  • Examples of In-Network Reimbursement
  • Examples of Out-of-Network Reimbursement
  • Possible benefits of going Out-of-Network
  • Examples and general guidelines to state regulations for Out-of-Network and balance billing
  • No Surprises Act
  • No Surprises Act: good faith estimate
  • Life of the claim: Revenue Cycle Management
  • Denials and how do we deal with them?
  • Appeal process
  • Appeal rights for in and out of network providers
  • How to appeal?
  • Appeal example: Medicare
  • Appeal example: Medicare 2nd level
  • Medicare Appeal: Process Summary
  • Appeal example: AETNA
  • Appeal example: BCBS (Blue Cross Blue Shield Association) of MD
  • Appeal example: CIGNA
  • Appeal example: UHC (United HealthCare)
  • Appeal attachments
  • Ways How to be Proactive
  • How to have a better control of your practice?

Suggested Attendees

  • Medical providers, who are involved in the payment process of their practice
  • Physicians
  • Practice Managers
  • Billing Managers
  • C-level executives
  • Office managers
  • Medical billers
  • Medical Coders
  • Office staff and Billing Managers
  • Medical Billing Companies
  • Providers’ Office Staff
  • Hospital Revenue Cycle Staff

About the Presenter:

Kate Gilman CPC, CPCO has almost two decades of experience in the healthcare industry. She is an expert coder, compliance officer, and trains healthcare providers all over the country. Kate utilizes her expertise to uncover ways to improve billing and coding inefficiencies, training staff, and ensuring compliance while achieving maximum results and revenues for her clients.Kate’s successes include small and large practices, ranging from primary care to specialists and surgeons. She is known for helping providers feel confident in their coding and peace of mind with their compliance practices. Kate’s acute attention to detail, deep understanding of coding and billing, and proactive approach make her an indispensable asset to all her clients.

Course Content

You can access all the webinar materials after successful payment

  • Webinar Link + Handouts PDF
  • Course Link
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