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5 Key Revenue Risks of Out-of-Network Claims

1. Delays Due to Credentialing Gaps

   When a clinic launches a new location or brings in new providers, getting credentialed by insurance carriers can take months. During this period — often up to 120 days for individual providers and as long as a year for new clinics — payers may deny reimbursement altogether. Seeing patients before full credentialing is finalized can severely impact early cash flow.

2. Non-Compliance Pitfalls

   Some providers try to navigate credentialing delays by billing under an already credentialed colleague. However, this practice can lead to serious consequences. Violations of payer policies or federal billing regulations may trigger audits, recoupment demands, contract termination, or even DOJ investigations resulting in costly settlements.

3. Limited Interim Billing Options

   Urgent care settings rarely qualify for billing workarounds such as Locum Tenens or "incident-to" billing. This makes it especially hard for clinics to receive payment for services performed by non-credentialed providers. As a result, providers may be effectively working without reimbursement during onboarding phases.

4. Unpredictable Reimbursements and Denials

   Even when out-of-network claims are accepted, payment is never guaranteed. Insurers may:

   • Send reimbursement directly to the patient,
   • Apply the costs to the patient’s deductible, or
   • Deny the claim completely.
   
   

   This lack of consistency undermines billing teams and reduces overall collection rates.

5. Decreased Patient Volume

   To offset OON billing challenges, clinics may request upfront payment or full cash fees from patients. However, this can deter visits, reduce retention, and damage the clinic's community reputation. Patients may avoid care altogether if they feel financially unprepared or uninformed.

Best Practices for Managing OON Claims

While the challenges are real, urgent care clinics can reduce risk and improve reimbursement outcomes by adopting a few core strategies:

• Understand Payer Rules and OON Policies

  Carefully review insurer-specific rules regarding out-of-network reimbursements. Know whether emergency-only coverage applies and what documentation is required to support your claim.

• Verify Coverage Before Services Are Rendered

  Always confirm whether the patient’s insurance includes OON benefits — and if not, communicate expected charges upfront. Verifying eligibility early reduces denied claims and surprises later.

• Seek Preauthorization When Applicable

  Some payers require preauthorization for OON care. Even when not mandatory, having a documented preapproval on file can smooth claim submission and reduce friction during reimbursement.

• Submit Clean, Detailed Claims

  OON claims require precision. Ensure coding accuracy, complete documentation, and inclusion of any supplemental forms specific to out-of-network billing.

• Educate Patients and Offer Transparent Payment Options

  Avoid miscommunication by clearly explaining your OON status, potential out-of-pocket costs, and available financial assistance or payment plans. Patients are more likely to return if they feel informed and supported.

Managing out-of-network claims doesn’t have to drain your revenue cycle or frustrate patients. At No Surprise Bill, we specialize in simplifying OON medical claims processing for urgent care centers and healthcare providers, helping you minimize denials, reduce compliance risks, and accelerate reimbursements. Don’t let hidden revenue risks impact your bottom line — partner with us for expert claims support and patient-friendly solutions. Contact us today to streamline your OON billing process and protect your revenue.