Low reimbursement can leave a private practice owner wondering whether a full schedule is worth the work it takes to maintain it. But leaving a payer network raises another concern: What if patients stop booking — and getting back into the network proves difficult?

Before giving notice, estimate how much income is at risk, how many patients are likely to stay and what returning to the network would require.

What does this payer actually contribute?

Review a recent 12-month period, allowing enough time for claims to be paid. For each payer and relevant product, pull completed visits, unique patients, collections, payment delays, denials and the staff time spent resolving problems.

Use collections from both the insurer and patients. Comparing an insurer’s payment alone with a self-pay fee can exaggerate the difference if patients also owe deductibles, copayments or coinsurance.

Compare similar services and visit lengths. A payer with more complex visits may generate more revenue per encounter while consuming considerably more clinical time.

Separate two problems:

1. Low contracted rates: The practice is being paid correctly, but the agreed amount is inadequate.
2. Payment below the contract: Incorrect payments, unresolved denials or collection problems are reducing what the practice receives.

The second problem calls for payment recovery and process correction before concluding that the contract itself is unworkable. Then distinguish costs that would disappear from those that would remain. Fewer claims might reduce an outsourced billing fee. They will not automatically reduce rent, software subscriptions or a salaried employee’s pay. Time recovered from appeals has value, but count it as a cash saving only when spending falls.

A low-paying contract can still help cover fixed expenses when appointments would otherwise sit empty. The math changes when the practice has demonstrated demand from patients with better-paying coverage or patients willing to pay directly.

How many visits would you need to replace?

Build a simple estimate using the amount left after visit-related costs.

Consider this hypothetical example:

The current payer contributes $8,500 monthly toward fixed costs and owner compensation. At $140 per self-pay visit, the practice would need approximately 61 completed visits to replace that contribution.

That does not mean retaining 61% of patients guarantees success. Patients may visit less often when paying directly. New-patient and follow-up visits may have different prices and lengths. Discounts, failed payments and added marketing costs can change the result.

Run the same calculation for patients covered by plans you intend to keep, using actual collections and visit-related costs. Check whether demand from those patients could fill the openings.

Run several scenarios — for example, retaining 30%, 50% and 70% of the affected visit volume. As part of these planning assumptions, include the time needed to attract replacement patients and the cash required during that period.

Also account for the temporary cushion from old insurance claims. Payments for care delivered before termination can make the first few months look healthier than the new appointment volume supports. Track collections by service date as well as cash received.

Is there evidence patients will pay directly?

A full schedule under an insurance contract does not establish demand at a self-pay price. Start with patients’ likely out-of-pocket change. Moving from a modest copayment to the full visit price is different from moving from a high deductible to a comparable cash fee. Recurring care also creates a larger household expense than an occasional visit.

Ask affected patients about specific prices and visit frequency. A general question such as “Would you stay if we stopped accepting your insurance?” can produce reassuring answers that do not translate into bookings. Review:

• Existing self-pay inquiries that became completed, paid visits.
• Referrals that depend on in-network participation.
• The coverage held by patients on the waiting list.
• Local access to comparable in-network clinicians.
• Patients likely to need help transferring care.

A waitlist of patients who need insurance coverage cannot necessarily fill openings at the proposed price. Review existing self-pay patients’ fees, return visits and referral sources. Their behavior at current prices may not predict demand at a higher fee. Model a proposed price increase separately from leaving a payer, and confirm that any test complies with existing agreements and billing rules.

Could a smaller change solve the problem?

Dropping one poorly performing contract and becoming entirely self-pay are different decisions. Self-pay can mean payment per visit alongside selected insurance contracts, subject to applicable agreements and billing rules. It does not require a direct primary care model, which typically charges a recurring fee for defined services.

Ask whether your agreement allows you to stop accepting a plan’s new patients while continuing care for established patients. Confirm approval, notice and directory requirements first. This can test whether other patients fill openings, but not whether established patients would stay without in-network coverage.

Before leaving, make a specific request for improved terms. Identify the services driving the problem, the requested rates and the date by which the practice needs an answer. Document access the practice provides, such as appointment availability or services that are difficult to obtain locally.

If negotiation fails, consider whether leaving one contract would provide enough relief. Review termination notice, restrictions on leaving individual products and post-termination obligations before proceeding.

• MGMA members can download an exclusive Payer Contracting Playbook.

What would returning to the network require?

“Recredentialing” is often used loosely to describe returning to an insurer. In practice, verifying professional qualifications, negotiating a contract and establishing an effective participation date are separate steps.

Aetna, for example, has a participation process that includes evaluating network needs, contracting and credentialing. A request may be denied when the panel is closed or the insurer does not intend to pursue a contract.¹ Previous participation should therefore not be treated as a guaranteed route back.

Before terminating, ask the payer in writing:

• Would a former participant need a new application, contract or credentialing review?
• Is there a waiting period or other restriction on reapplying?
• Could the panel close to the practice’s specialty or location?
• What determines the new effective date?
• Would prior rates remain available, or would terms be negotiated again?

A current estimate cannot guarantee future acceptance or timing. Build a financial plan that can tolerate a longer interruption.

Keep credentialing information and supporting documents current, and preserve copies of the agreement, termination notice and correspondence. If returning becomes necessary, confirm the effective date in writing before representing the practice as in-network.

Returning could make business sense if replacement demand falls short, important referrals decline, patients cannot afford ongoing care or the payer offers better terms.

What must patients know before the change?

Review the contract, payer requirements and applicable state rules before setting a termination date. Coordinate notice deadlines, ongoing treatment, outstanding claims and patient communications.

Leaving a network does not automatically end the responsibility to support patients through a care transition. AMA ethics guidance calls for sufficient advance notice and facilitation of transfer when ending a patient-physician relationship.²

Some patients also have continuity-of-care protections. CMS explains that eligible continuing-care patients may retain in-network terms for up to 90 days after a provider leaves a network. Eligibility and implementation must be checked; this is not a blanket extension for every patient.³

• Give patients plain answers: the affected plan and effective date, the proposed fee, payment timing, options for continuing care and how to request records or assistance transferring.
• Explain what the self-pay fee includes, including how the practice handles messages, refill requests, forms and after-hours concerns. Set clear response times and identify services billed separately. If the proposed offering includes longer visits or more between-visit support, account for that work when setting prices and estimating capacity.
• Distinguish paying entirely out of pocket from paying an out-of-network clinician and seeking insurance reimbursement. If the practice provides a superbill, explain that it documents services; it does not guarantee payment. Patients should verify their own out-of-network benefits and deductible.

For uninsured patients and patients choosing not to use insurance, incorporate applicable good faith estimate requirements into scheduling and billing. CMS provides guidance on when written estimates are required.⁴ A posted fee schedule alone is not the whole process.

Does the plan include Medicare or Medicaid?

Handle government coverage separately from commercial contracting.

• For eligible clinicians, Medicare private contracting generally requires a formal opt-out affidavit and private contracts with patients. Opt-out periods run for two years and renew automatically unless properly canceled; CMS describes a limited early-termination opportunity for an initial opt-out.⁵ Medicare nonparticipating status is different from opting out.
• Before collecting privately for Medicare-covered services, confirm the applicable requirements with the Medicare Administrative Contractor and knowledgeable counsel. Likewise, verify state Medicaid and Medicaid managed care rules before offering cash arrangements to beneficiaries.

How will you know whether the change worked?

Set review dates and decision thresholds before giving notice. Monitor completed visits, collections tied to post-transition services, cash reserves, new-patient bookings, administrative hours and patient transfers.

Define success in terms the owner can use. A somewhat smaller patient panel may be acceptable if income is sufficient and work hours improve. A higher payment per visit is insufficient if the schedule cannot support the practice.

Choose an early point for corrective action—before reserves become depleted. That could mean revising prices, strengthening referral outreach, reducing expenses or beginning discussions about network participation.

The practice should be able to finish this sentence before leaving: “We can sustain this change if we complete at least ___ visits a month, collect ___ and keep cash reserves above ___.”

Sources

1. Aetna. “Request to join the Aetna network.” https://www.aetna.com/health-care-professionals/join-the-aetna-network.html 
2. American Medical Association. “Terminating a Patient-Physician Relationship.” https://code-medical-ethics.ama-assn.org/ethics-opinions/terminating-patient-physician-relationship 
3. CMS. “Action Plan: Doctor going out-of-network.” https://www.cms.gov/initiatives/your-patient-rights/medical-bill-rights/get-help/find-action-plan-your-medical-bill/action-plan-doctor-going-out-network 
4. CMS. “Good faith estimates.” https://www.cms.gov/medical-bill-rights/help/guides/good-faith-estimate 
5. CMS. “Manage Your Enrollment.” https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers/chain-ownership-system-pecos/manage-your-enrollment