E/M Coding Alert - 2017 Issue 7
The In's and Out's of OON Billing
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Article Overview
This article explains the business appeal and compliance risks of out-of-network billing for healthcare facilities. It focuses on transparency, patient payment handling, payer reimbursement issues, and the legal theories that can arise when OON billing practices are viewed as problematic. The discussion is aimed at providers, facility administrators, and billing/coding professionals who need a high-level view of OON billing risk management and compliance-minded operating practices.
Why This Topic Matters
Out-of-network billing can affect revenue, patient relations, payer behavior, and fraud exposure. Understanding the article helps organizations evaluate billing practices that may create legal or operational risk and identify broad compliance safeguards.
Article Sections
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OON Billing Risks and Payer Behavior
Introduces the business and compliance issues associated with out-of-network billing and summarizes why payers may resist these claims. It also describes broader market and operational factors affecting OON participation.
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Examples of Legal Exposure
Reviews representative legal matters discussed in the article and the types of allegations connected to OON billing practices. The section frames the legal and enforcement landscape at a high level.
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Best Practices for Compliant OON Billing
Outlines general compliance-oriented topics for facilities that bill out of network, including disclosure, patient payment handling, charge practices, and referral-related concerns.
What You Will Learn
- Why out-of-network billing can create both revenue opportunities and compliance risk
- What broad categories of payer resistance may affect OON reimbursement
- Which general operational practices are discussed as areas of legal concern
- How the article frames disclosure and documentation as part of OON billing compliance
- What types of compliance topics are associated with patient waivers, charge setting, and referral relationships
Who Should Read This
- Healthcare providers
- Ambulatory surgery center administrators
- Billing and revenue cycle staff
- Compliance officers
- Medical practice managers
- Healthcare attorneys and consultants
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