There are pros and cons to everything.

Pros:

You are not obligated to send a claim. That is the patient's contractual responsibility outline in their contract with their insurance company. As I have said many times, if you send a claim, you are sending the patient's claim to have their benefits paid.

You can collect 100% at the time of service. It helps greatly if you tell the patient this before they come in. The patient has a right to be told this and has a right to make a freedom of choice decision to leave and seek care from a network provider.

As a non-contracted provider, any policy and procedure that the insurance company has, has no jurisdiction over you. Again, these are patient claims and patient benefit issues you are dealing with.

If the patient pays you and submits a bill for reimbursement and the insurance company sends you a letter asking for a claim, you can tell them to jump a rope or pay you an administrative fee for processing a claim. Again, you have no obligation to send them a claim. The contract with the patient makes it the patient's responsibility.

Cons:

If you do't ask for payment at the time of service and you choose to send a claim, the carrier can send the payment of the benefit to the member.

The carrier has no legal obligation to talk to you about the patient's claim.

The carrier might send you payment, but it may not be the amount of your charges. Now you have to fight with the patient to get the rest of your money.

You have no appeal rights. This is because it is the patient's benefit that needs to be appealed and the patient has the appeal rights not you.

If you play the claim game, the claim may be denied because the patient never obtained authorization to see you, now you are back to dealing with the patient again.

The insurance company can ask the patients not to use your services. The insurance company can say, Patient, if you go to Doctor X, we will not pay for the benefits or we will pay $X and you pay the balance.


If you elect to remain contracted, you have a case if the insurance company doesn't pay you correctly. You can take the insurance company to court and you have a contract to back up your case, that is, if you have a good contract.

If you elect to remain contracted, you do have appeal rights because it is a contract issue you are appealing. Hopefully the contract will outline and detail the appeals process.

Remaining contracted is only as good as the contract that was signed.