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Five Common Myths About Out-of-Network Ambulatory Surgery Center

April 14, 2021

Group DocsShould you consider running an out-of-network ambulatory surgery center? While it may not work for everyone, it’s not as crazy as you might think. Plenty of myths have circulated surrounding out-of-network ambulatory surgical centers, yet the truth behind those myths shows that there are some key opportunities available if you do decide to continue with out-of-network offerings.

Myth #1 – You’ll Maximize Reimbursement by Being 100 Percent In-Network

The Truth:

While you may believe that the way to obtain the highest amount of reimbursements is to stay in-network, experts believe that having a good out-of-network strategy combined with the right expertise may be able to increase your overall reimbursement. Creating a hybrid out-of-network and in-network strategy can offer the best pay-off. Even if you only make out-of-network payments a small part of your surgery center business, there’s an opportunity to increase payments.

While it depends upon your marketplace, many surgery centers have the potential to use the hybrid model to maximize revenue. You’ll need to determine which payers to pursue this strategy with based upon reimbursement levels compared to the levels of reimbursement if your surgery center was in-network with that payer.

Myth #2 – Out-of-Network Surgery Centers Aren’t Viable Anymore

The Truth:

Although some believe that going with an out-of-network surgery center isn’t a viable, profitable strategy today, there are opportunities to improve your reimbursement, even with increased responsibility, limited benefit insurance, and higher deductible copays. According to Becker’s ASC Review, there continues to be around $60 billion of out-of-network claims that get processed every year, proof that this segment isn’t going away.

Certain market trends like PPO enrollment, which continue to grow, also drive patients to pursue these out-of-network opportunities. People are willing to pay for out-of-network benefits, and payers continue to offer them.

Myth #3 – You Can’t Justify the Strategy with Few Out-of-Network Patients

The Truth:

Even if you only have a very small percentage of out-of-network cases, it can make a significant difference in your surgery center’s revenue. The Anesthesia Consultant notes that it’s not unusual to see out-of-network reimbursement be up to five times as high as contracted reimbursement rates. If even a small percentage of your patients are out-of-network, these higher reimbursement rates can end up accounting for a large percentage of your reimbursements each year, boosting your bottom line.

Myth #4 – All Billing Companies Can Handle Out-of-Network Strategies

The Truth:

If you decide to have a hybrid in-network and out-of-network strategy, one of the worst things you can do is think that your billing company has this handled. While billing companies are specialists in medical billing, it’s critical to work with a medical billing company that specializes in handling out-of-network billing and negotiations. Find out if your billing company has good results dealing with out-of-network negotiation requests and when they appeal out-of-network under payments or denials.

Myth #5 – It Doesn’t Make Sense to Outsource Billing

The Truth:

Most surgery centers look for ways that they can cut costs, and enlisting the help of experts can help you do so. When you try going out-of-network without the right training and experience, it can be difficult to succeed, which is why it can be helpful to outsource your out-of-network billing to a company that has plenty of experience handling this type of claims. Partnering with a medical billing company that can help you maximize what you bring in from your hybrid in-network and out-of-network strategy makes it well worth the investment.

Yes, running an out-of-network surgery center can offer benefits, and having a good hybrid strategy between in-network and out-of-network payers can boost your bottom line. The key — knowing your market, creating a good strategy, and working with an experienced billing company. If you’re looking for a quality medical billing company that can help you maximize your out-of-network reimbursements, M-Scribe can help. Contact us today at for more information.


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