There are many factors that patients consider when deciding to come to your practice:

• They trust you and value the care you provide.
• You are recommended by a trusted health care provider, friend, or family member.
• Your location, availability, hours, and days of operation meet their needs.
• You provide a level or type of clinical expertise that they cannot get elsewhere.
• You provide a level of service that they cannot get elsewhere.

Consider whether the services you offer are sufficient to convince patients to choose to come to your practice despite the out-of-pocket costs. Keep in mind that if a patient can receive the same value or same service from an in-network provider with no out-of-pocket cost, he or she will likely choose to stay in-network.

The demographics of your community are important to consider when deciding whether to transition to a cash practice. The US Census Fact-Finder database and City-Data are useful sources of information about regional demographics.

Don't jump to the conclusion that patients will not pay for services out-of-network. Take a look at the other businesses and health-related services in your community and consider their success. Pay close attention to other out-of-pocket services such as massage therapy, chiropractic, and acupuncture. Are well-managed health clubs and exercise facilities thriving in your community? Are there specific services that you can provide that would meet a need and result in an increase in out-of-network patients? Possibilities include:

• Adolescent sports rehabilitation and performance enhancement.
• Chronic disease management.
• Management of complex orthopedic conditions.
• Hand therapy and splinting.
• Women's health.
• Cancer rehabilitation/lymphedema management.
• Wellness and prevention.
• Direct to employer services.

Transitioning to Out-of-Network
Although physical therapists may decide to make an immediate transition to out-of-network status for all payers, a gradual approach is more common. Consider starting with 1 or 2 payer contracts that don't cover your costs. This will allow you to evaluate whether patients are willing to pay the additional out-of-network costs.

Setting Your Fees
Regardless of whether you are in-network, out-of-network, or a hybrid combination of the two, it is recommended that you bill based upon a single fee schedule for all of the services that you provide. The insurers that you contract with will pay you the discounted fee that you have agreed to accept. The public insurers (Medicare and Medicaid) will pay you based upon their fee schedule. You can still provide discounts to patients who see you out-of-network and pay you at the time of service, to patients with financial hardships, and in other situations when you determine a discount is warranted. It is good practice to establish a policy for discounts and apply them consistently.

Time of Service Collections
Read APTA's resource Collection of Copays, Deductibles and Other Patient Fees to begin developing your payment and collection policies. The following are several suggestions for best practice in collection of fees:

1. Develop a written financial policy for all patients and clients to read and sign.
2. Train your clerical staff that collection of patient fees is a critical component of their job. Teach them to communicate with patients openly and honestly about your policies.
3. Implement a fast and effective way to verify patients' eligibility and benefits before the service is provided so that patients will know what their out-of-pocket costs are likely to be.
4. Accept the full range of payment methods including credit cards, debit cards, electronic checks, personal checks, and cash.
5. Review all existing payer contracts to see if any prohibit you from collecting for non-covered services.
6. Consider posting (or making available) a list of the services that you offer and your fee schedule. This can also include noncovered services such as group classes and fitness training.
7. If appropriate for your practice, establish a written discount policy applicable to patients who have financial hardship, pay at the time of service, or meet other conditions that you decide merit a discount. Be consistent in your application of this policy.

Steps for Discontinuing a Payer Contract
There are several things you should do if you are considering terminating your agreement with a third-party payer. First of all, take a look at your metrics and determine the impact that this termination will have on your practice. Make certain that you have exhausted all possibilities for negotiating a more favorable contract with the payer. If your APTA state chapter has a Payment Specialist or Payer Relations Committee, ask if they have information or suggestions that might help you avoid terminating a contract that you might want to keep.

If you decide that terminating the contract is in your best interest, or if you are transitioning to a fully out-of-network practice, there are several steps that you should take.

1. Obtain appropriate professional advice and necessary permissions. If your practice is governed by a board or management team or if your clinic is part of a larger organization, make sure you have the authority and permission to terminate a contract. In many cases, it is good idea to discuss the contract termination with your attorney and perhaps have the attorney draft the termination letter and oversee the transaction. Consider discussing your decision with your accountant so that you fully understand the financial impact of your decision.
2. Review the contract. Take a look at the contract or agreement that you have with the payer. Review the section on termination to determine the length of the term of the contract, how long you must participate as a provider before terminating, whether you may terminate without cause, and the amount of notification that you must provide.
3. Notify the payer. Send all correspondence related to contract termination by certified mail and request a returned receipt. Follow up with the payer by telephone to make sure the payer's computer system has been updated. Address the termination letter to the contact person listed on the contract or to the contract administrator. Indicate the effective date of termination that is within the range specified in the contract. If the contract allows termination without cause, you may simply indicate that you are terminating the agreement effective on a specific date and should not be required to provide other information. If the contract requires that you give cause for termination, you will need to be more specific and may need to provide supporting documentation for your decision.
4. Notify your patients. It is important to inform your patients of your decision to become an out-of-network provider for their insurance payer. Hopefully, they will decide to continue to see you for care despite your change in status. Send a letter to your active patients who are insured under the insurance plan and inform them of your plans to terminate your practice's in-network status and give them the effective date of the termination.

Avoid focusing the letter on your frustrations and anger toward the insurance company. Focus instead upon the reasons that you believe that your practice will be able to offer them the best care and service for their problem. Encourage them to contact your practice administrator or front desk personnel for help in determining what their out-of-pocket expenses will be with your new out-of-network status.

Offer time-of-service discounts and an option for payment plans to encourage them to continue as your patients. Indicate that your practice will be happy to help them find another provider if they should choose to stay in-network for their care. End by thanking them for choosing your practice for their physical therapy care and provide a contact name and number that they can use for questions and concerns.

5. Inform your staff. Make sure that your administrative staff is informed of your decision to terminate the payer contract. Since they are the likely point of contact for patients on issues related to payment, make sure that you carefully script the message that they provide to patients who call or visit your clinic.

Instead of saying, "No, we don't take that insurance," have your staff say, "Yes, we are out-of-network for that insurance. However, your insurance company should pay a substantial portion of your charges if you receive care at our practice. I am happy to contact them and provide you with an estimate of what your out-of-pocket costs will be, if you would like." You may also have them add a statement such as: "Our practice offers a __% discount for payment at the time of service and will bill your insurance company as a courtesy to you. If you would like to talk further about establishing a payment plan, I am happy to have someone call you."

Have your front desk staff be prepared to discuss this decision in person with your active patients, again focusing on how much the practice would like to retain them as patients. Offer to help them in the ways discussed above.

The clinical staff should also be informed about the decision so that they can engage in helpful conversations with patients about the decision to be an out-of-network provider. When discussing this topic with patients, physical therapists should focus the conversations on the patients' needs and how to best help them reach their goals.

When discussing the plan of care with the patient, the physical therapist should mention the out-of-network status of the practice and make certain that the patient is able to afford the visits necessary to reach the goals. Many times, modifications can be made in the plan of care that allow the patient to still achieve the goals through increased emphasis on home program or other adjustments. In other cases, it may be necessary for the physical therapist to help the patient find another practice within their insurance network to receive the care they need.

6. Inform your referral sources. If there are physicians or other health care providers who frequently refer patients to your practice, it is a good idea to inform them of your decision to terminate a payer contract. This will prevent them from being surprised when they refer a patient to your practice. It is best that they hear this news from you instead of from their patients.

You should briefly explain the reason for termination and focus on your desire to provide the best care for their patients. Mention in your letter that you understand that not all patients will want to choose an out-of-network provider. However, you should make clear that you would still appreciate these referrals and describe the ways (mentioned above) that your clinic will make it easy for these clients to receive care at your practice. If your practice offers a clinical specialty particularly one not offered elsewhere in the community, it might be helpful to describe the types of patients that would most benefit from seeing you as an out-of-network provider.