Out-of-network services toolkit

The health care industry is one of the only industries in which over 80 percent of the revenue for services comes from parties other than the consumers themselves. Typically, the majority of physicians’ revenue is derived from health insurers or other third-party payers. Therefore, physicians need to hold health insurers accountable to their agreements and/or payment responsibilities. This need to hold health insurers accountable is applicable even to physicians who are not contracted with the health insurer. Out-of-network physicians should protect themselves and their patients from unfair payment reductions.

The AMA's Practice Management Center (PMC) has developed the following resources to help physicians and their practice staff in dealing with payments for out-of-network services:

Holding health insurers accountable for out-of-network services  (PDF, 44KB)

Out-of-network payment challenges for the physician practice  (PDF, 39KB)

Sample letter to obtain additional information regarding UCR calculation by payer  (PDF, 21KB)

Is your practice losing revenue through inappropriate health plan adjustments?
 (PDF, 176KB)

Helping your patients understand their billing and payment responsibilities  
 (PDF, 324KB)

Health plan settlements - The AMA has compiled pertinent information regarding the Multi-District Litigation Settlements and the Blue Cross and Blue Shield Settlement along with tools that may be utilized as a resource.

Assignment of Benefits & Balance Billing Laws (PDF, 133KB)