7 Deadly Mistakes Made By New Practice Startups

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10: Checklist for Out of Network Benefits

Sharon, a SLP from Washington State emailed me recently (actually while I was in the hospital passing a kidney stone — there’s a first time for everything, right?!) regarding out-of-network benefits (OON). In this podcast, I discuss a checklist that you can use in your business to process referrals that are out of network in your clinic.

In - Out Network

In this episode:
01:01 – Many THANKS for the emails, tweets and feedback
03:04 – Esther is taking the wheel
04:14 – Hanging out of the car and sick as a dog
04:40 – Checklists, checklists, checklists
05:10 – The left-handed nurse
05:45 – Physicians, nurses and hospitals follow a checklist – we should too
06:50 – 2 mm kidney stone and the email from Sharon the SLP
07:35 – Out of network benefits and a checklist for action
08:13 – The referral
08:40 – Payer source
08:43 – Eligibility at the time of the referral
09:09 – The need to decrease financial ambiguity
10:01 – The out-of-network benefits (OON) for speech therapy services
10:35 – Cost of Care / Cost of Evaluation
10:56 – Pricing and Out of Network Benefits (OON)
11:30 – In-network (IN) and Out-of-network (OON), two different sets of rules = play fair, play well

Download PDF Transcription

Transcription of Episode Ten:

There’re going to all these checklist as they’re bringing me back to the backroom and it was highly standardized and the treatment was really good.

Well, Hello everyone! You’re listening to the Speech therapy Private practice Startup Podcast; this is episode number 10. My name is Kyle Meades and I’m a speech and language pathologist since 1993 and these podcasts are designed to help you improve your business and your life one podcast at a time.

I want to start out like I do all my podcast and say thank you for listening to the podcast, thank you for sending me those questions via email, thank you for sending me those tweets and to let me know that you guys are listening out there. Its because of you guys out there we now have over 2000 listeners to the show from all part to the world and every state in united states. It’s because of you guys leaving good solid feedback on iTunes that other people can find the podcast easily. I want to give you guys value and I know I sound like a broken record but values is what you get in the absence of money. Listening is free for you guys and I want you to get the latest best information out there to help you either start or grow or improve your speech therapy private practice. And I just again want to say thank you, I really appreciate it and I want to start out this podcast with a Story.

OON Benefits

So yesterday I am on the way taking my son to school about 07:30 and the way we go to school we go right past the speech therapy clinic. And my son always like, “Dad, there’s the speech therapy clinic.” And I said, “Yes sir, there it is”. New office, new place and this time he points to it and I see Esther, she is our Office manager. She is always back into her parking spot right there. But this time I had to turn in and he said, “Dad, where you’re going?”. I said, “Son, dad didn’t feel great and must meet attorney. I couldn’t even finish driving my son to school. I had the most excruciating pain the night before. I tried to take hot bath, I tried to get rid of it. I thought it will pass, I didn’t know what was going on. I am sucking it up to get my son to school on time and I just cant even drive the car so I pulled into the clinic and I banged on the door. Esther comes out and she says, “Hey”, and I am like all my interior. I said, “Esther, can you please take my boy to school? He tell you how to get there. He knows how to do this.” She said, “Whats wrong?”. I said, “I am in such bad pain. I cant even drive.” She gets the keys and she gets behind the wheel and all she goes to take my son to school.

And then I just kind of curl up in the fetal position in my office and couple of people they hear me. And they want to say, “Hi Good morning Kyle, how are you?”. You know how Speech pathologists are, they always want to figure out whats wrong and treat the problem. That’s how speech therapists are, we’re neurologists, psychologists and educational specialists. We’re all that stuff combine into one little package. So Christine comes in and she says “Oh my god, whats wrong with you?” And I’m like, “Awwwwww…” anyway she says I was stuttering, my pain was so bad.

Esther comes back after taking my son to school. She come in and says “Kyle, we cant have you here like this. You need to go to emergency room right now.” I said, “You know what I hate the hospital but I’ll do it.” We lease from Tucson Medical Center so we’re right across the street from the hospital. So she puts me in the car and drives me across the street and as soon as we get across the street, I am opening the door, I start vomiting I know it sounds gross but the pain was so bad. I just started throwing up in the parking lot while we were moving and I am just like get us to the hospital. I don’t know whats going on I have never ever experienced pain like this in my whole entire life.


So Esther gets to the front door of emergency room, they came out and get me to the wheel chair, they roll me into the ER there and I didn’t have to wait and gave them Blue Cross Blue Shield card and gave a copy of my license, they are going to these checklist. They need this and that information; are you allergic to anything. They were going to all these checklist as they’re bringing me back to the backroom and it was highly standardized and the treatment was really good. So I get into this backroom and then there was a nurse that came in and I really don’t even remember what was going on because I was in so much pain. I am on the ground like on my knees with my head against the gurney there. And this left-handed nurse, the reason I know she was left-handed is because I am left-handed too. She says, “This is classical kidney stones.” Anyway she comes in, this is before the Doctor comes and she’s been around. You can tell, she knows her stuff, she was very confident.

The nurse comes in and she can just tell I was in all this pain. She came up to me, “Mr. Meades, did you have anything to eat? Did you have a bowel movement? Did you pee today? All these standardized questions, because that’s what doctors, physicians and nurses do, they have a list of procedures that they have to follow. And I’m listening all this I can barely speak because I am in pain. Anyway to make a long story short finally the physician’s assistant didn’t even see a medical doctor. I saw a PA she came in she knew exactly what it was. She said, “Oh, you got kidney stone, this is classical.” I said, “Yeah that’s what the left-handed nurse said 30 minutes ago. But can I please have something for the pain.” And for those of you who know me out there folks, I don’t drink, I don’t take drugs, I don’t take anything, I am a nerd. I am a good person. And I just said, “Look you got anything Non Narcotic” and they said, “Look, trust me you want something for this pain.” Anyway they gave me some Non Narcotic injection. And it really worked, and then I went to CAT scan. You get the CAT scan and they get all this standardized procedures. They’re asking you all these questions; do you have metal inside your body? Do you have ever had surgery? again procedures and standardization. So we get through all of that and make a long story even longer.


About 4 hours later, 2mm kidney stone, here’s your discharge paper, everything standardized again, checklist after checklist. Go home drink lots of water, take this medications, you should pass this little thing in about next 4 to 7 days. So here we are the next day sitting here and listening all of this stuff and going through all this checklist and answering all of this questions.

I thought about this email that this lady named Sharon; she is a speech pathologist in Washington State. She says to me, “Kyle, Thank you so very much for the Podcast. I find them informative and they’re really helping me grow my private practice.” She says, “Hey, I have a question. When you receive a referral if it’s a pair that you are in contracted with, do you still call and schedule that family? And if so how long do you wait before you actually call them?” Great question and we have a checklist for that that we use in our office.

So I got online this morning and pull some forms out of our online forms there and I wanted to read you guys these steps that we take for our referral when we don’t take that pay resource. So this is good information and can you believe how I tied all this stuff in from my Kidney stone to a checklist for a payer that we’re not contracted with.


Office Window

So here it goes, number 1, you receive the referral and the referral will usually indicate who ever the payer is.

So you go to number 2, the Payment source. Now in our clinic, users are going to be Private Insurance, Medicare, Medicaid or Cash.

Number 3, Eligibility at the time of referral, Why is that important? That’s important so when you speak to that family and get them on the schedule, you can kind of give them an estimate how much it’s going to cost. People want to know what it’s going to cost, don’t forget. Healthcare is the only business where everything is just financial ambiguity at its find. I went to the Hospital yesterday, I gave him an Insurance card, I don’t know how much they’re going to bill me. I don’t know how much they are going to collect from me. I don’t know the final amount. It’s the only business where we don’t have a final answer but I tell you what its very important when you call and schedule your patients you want to given them a range, we don’t take your insurance but based on our experience the phone call we have with your Insurance company today, 80% of its going to be covered and here is the amount that we are going to charge your Insurance company and 80% of which is X amount of dollars is going to paid for so you are going to be left with 20. So the range is going to be anywhere from 150 bucks which is our cash way up to 190 bucks. So there’s the range you can give the family because they have a right to know about what there cost of care will be. So that’s why you want to check the Eligibility at the time of the referral.

Number 4, you want to find out the out of network benefits for speech therapy. You ask if the patient has met there the doctor for this year and the representative should be able to tell you the actual amount that patient has spent on their medical care up to this date. So for instance, if you are in urgent when you call this people and get them schedule, they should be able to say, “Oh, so and so met their the Doc the last month, everything should be covered up to 80% over the plans going to get cover.

So number 5, you can then tell the family what their cost of care will be for the evaluation. You may even find that your Cash rate may be more affordable for that family rather than using their Out of Network benefits. Now here is something that you want to remember, since you are not contract with this Insurance Company you had the ability to price it that way because when you are not in network with this insurance company you are not bound to those terms of service. So you are able to say, “Look, here’s our cash rate and your Insurance will cover this amount and this would be your cost of care, so whichever wants cheaper.” That’s how we are doing in our clinic because people really like to have value.

So we are always say, “Look if you want to use your Insurance it’s going to be this much, If you want to do cash its this much, Its up to you what would you like to do. And once we make that decision, we have them sign and we are bound to those terms.

You can’t do that if you are in contract with Blue cross, Blue shield. You can’t just say, “Hey, they’re going to reimburse this and our cash rate is cheaper, so we’ll just go with cash. You can’t do that because if you get caught doing that when you are in contract their network with these Insurance companies, they can pay you and reimburse you that lesser rate because you’re doing that. You’ve got to follow the rules.

So I just wanted to give you guys this checklist, these five things that we do in our clinic when someone comes to our clinic and they have out of network benefits. So I hope this has been helpful for you guys. This is been a little bit of a story tell to as well because we all get sick. Thank the good lord above that we have insurance. Anyway I wanted to say Thanks again to Sharon for sending me this email and to kick this whole podcast off. It was because of that email I started to think about checklist, policies, procedures and kidney stone.

Thanks again to all of you out there who are listening to the Podcast and I’ll see you soon. Thank you!!


  1. Cathy Delfino says

    Hi Kyle,

    Thank you for all the information. Can you explain the wording of your explanation for why it would be beneficial for families to pay cash vs using their insurance? I feel like the copay amounts would always be less than paying for the service out of pocket?

    Cathy D

    • Kyle Meades says

      Hey Cathy, when In Network with insurance companies, there is a negotiated reimbursement rate to providers for service and there may be a patient copay and / or deductible /coinsurance amount due at the time of service. When Out of Network, there is no contract with the provider; Therefore, there is no negotiated rate and there may be a patient copay and / or deductible /coinsurance amount or “percentage of what is billed” for the cost due at the time of service. In the current healthcare environment, many copays now exceed the cash rate for the cost of care. As insurance companies place more financial responsibility on the consumer, It is something to keep in mind as you price your services, considering the amount of time and money it takes to bill and follow up with these companies. Thank you for the question.

  2. Natalie Alvarez says

    Thank you for your wonderful podcast! I am an OT who has been wanting to open a private practice, and your podcast has been the encouragement I needed to move forward with creating the plans for my business. I appreciate that each post has a practical application and concrete steps to follow. I am feeling much less overwhelmed about where to begin. Thank you!!

    • Kyle Meades says

      Thank you, Natalie. You should open that practice! Go for it and make it happen. At first it can be very overwhelming but after some time, it becomes less difficult. If you ever want one on one support, you should seriously consider joining the All Access Community (we actually have a BCBA and an OT in the community, too 🙂 There, I can meet with you weekly and coach you one on one!

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