By now, most providers and patients understand the network game. Doctors prefer the typically higher out-of-network reimbursement with no contractual restrictions, while patients would rather compromise on physician selection to use an in-network provider for the substantial out-of-pocket savings. What you may not know is that there is a happy compromise for both in your facility.

Across the country, surgery centers are billing insurance companies out-of-network when they refuse to negotiate favorable contracts, but billing their patients as if they were in-network. The surgery center gets the improved reimbursement, while the patient isn't penalized for having services rendered at an out-of-network facility. For instance, if a patient's out-of-network benefit is a percentage of billed charges, this will typically equate to two times to five times the contracted amount. However, the patient's co-insurance out-of-network may be a percentage of the total bill, sometimes in the thousands of dollars. But his co-payment for in-network may only be $50 to $100. You get the higher reimbursement, but your patients only pay his co-pay of, let's say, $100.

Seems too good to be true? Not yet it isn't. The only caveat is that you must notify the insurance company in writing how you're going to bill the patient. One suggestion: Drop all claims to paper that are eligible for out-of-network billing. Then, stamp the claim with a notice stating that you're billing the patient in line with his in-network benefit, regardless of how you're billing the insurance company. To ensure legal compliance, you may consider sending a certified or traceable letter to the insurance company in addition to the paper bill. This adds to the paper trail of notification to the insurance company so that there's no doubt that it has received notice of how you're billing the patient.

While there are a couple of extra steps in this process, the much higher reimbursement is worth the cost of the additional work. It's important, however, to make sure that the out-of-network benefit is significantly higher than the in-network benefit. More and more, insurance companies are aligning their benefits to be about equal - with some companies even having poorer reimbursement for out-of-network claims.

Amy N. Riley, RN, BSN
Vice President of Development
ASCOA
Mount Pleasant, S.C.
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Earning Back Lost Funds
Shortly after arriving at my present facility in January 2003, I discovered during an initial audit some really old, uncollected accounts receivable. Many of these billings were more than 12 months old, at least. While the clinical quality and staff at the center were great, turnover and mismanagement had apparently put the three-year-old facility through serious financial straits. I brought in a financial specialist I'd worked with before to help recover some of these funds, and motivated the business office to the task by reminding them that taking this proactive stance and extra step would have a huge impact on our center's success. Additionally, I put a portion of the money that was collected toward occasional holiday celebrations or picnic lunches for the staff in honor of their work. This, too, became a motivating factor. We collected more than $20,000 of really stale AR. It made a huge difference in the health of our organization, especially since hiring a collection agency would've meant giving up a much larger slice of anything we'd recovered. And it showed the staff that it's worth investing the time in a difficult task, especially when the effort can have a big influence in creating income for the center.

Nancy Petty, MBA
Administrator
Grand Valley Surgical Center
Grand Junction, Colo.
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Teaching Through Games
As quality services director for our community hospital, my portion of the orientation lectures for employees usually follows lunch. After once again witnessing the passive, apathetic faces of new hires forced to spend the day absorbing information, I was determined to find a new way to communicate what I had to teach.

Since people learn more effectively through interaction, I created a board game called "Infection Control ? Worst-case Scenario." The employees break up into teams and gather around the table. The object is to get your patient - your playing piece - through all the departments of the hospital, from admission to discharge, without developing a nosocomial infection. Various spaces on the board represent infectious incidents, but correctly answering questions about infection control rules will let your patient overcome those obstacles.

The game has had the effect we wanted. It's educated and engaged the new employees in infection control processes, promoted a team concept toward solving problems and opened communications during and after the orientation sessions.

Connie Meyer, RN, CIC
Director of Quality Services
Community Health Center of Branch County Coldwater, Mich.
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Ever Go to the Supply Room to Pull an Item and Find Out...
... that you're out of stock? My staff of RNs and scrub techs decided to divide responsibilities for the supplies among themselves. One got all the ophthalmic supplies, another orthopedic supplies, still others ENT supplies, sutures, general items and so on. They each check their areas daily or every other day, set par levels and help with inventory control. It's like having a whole team of materials managers. We've standardized surgeons' requests and reduced supply costs.

Joyce Danels, RN, CNOR
Director of Surgery
Twin Rivers Regional Medical Center
Kennett, Mo.
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