Key takeaways from this episode

• If you are out of network with a Medicare Advantage plan, stay out and keep your contract with the patient. When UnitedHealthcare asked an out-of-network practice to see its Medicare Advantage PPO patients without disclosing the out-of-network allowed amount, the advice was to bill the patient at the practice's own rate, give them an itemized bill, and let them file for their own out-of-network benefits.
• Do not bill the plan directly and accept whatever comes back. Since the No Surprises Act, payers typically pay out-of-network claims at or near their in-network rate and push disputes to arbitration, so filing the claim yourself effectively puts you in network at their price.
• Set a cash rate and collect before the service. A starting point like 150 percent or two times Medicare was offered only as an example; offer a discount for paying in full up front, treat it as a retail transaction, and do not let staff bill the plan on the patient's behalf.
• Always have the patient sign a financial agreement, and use an ABN only if another contract could create a hook. No ABN is needed for a truly out-of-network Medicare Advantage patient, but check for silent TPAs, IPAs and hospital-negotiated networks, and know state rules such as California's, where an unsigned agreement means you cannot bill the patient.
• Medicare Advantage is Medicare Part C, a private insurance plan, not traditional Part A and Part B. The plan must cover at least what Part B covers, but it adds prior authorizations, narrower networks and its own rules, and the Part B ABN rules do not apply to it.
• Expect Medicare Advantage networks to keep narrowing. CMS gave the plans essentially no increase for 2026 (about 0.0004 percent against an expected 4 percent), and plans respond by shrinking networks and matching out-of-network generosity to in-network rates to control cost.
• Your leverage is the provider panel. A projected shortage of 3,500 urologists over the next eight years and a growing boomer population mean plans need physicians to justify their existence; declining the contract is the one immediately effective vote you have.
• Before dropping a payer, know your demographics, your numbers and your collections capability. Freed-up schedule usually fills with better-paying patients, but nearby practices dropping the same payer can send you more of its members, and going out of network makes the patient your toughest payer to collect from.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 282, recorded March 2026, with Scott Painter and Mark Painter of PRS Network, and guest Dr. John Lin, solo practitioner in Gilbert, Arizona.

Out of network with UnitedHealthcare Medicare Advantage: the question

[00:00] Scott Painter: On this episode: how do you play the surgical lottery? Stay tuned. Welcome to episode 282 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter, and we welcome back special guest Dr. John Lin, solo practitioner in Gilbert, Arizona. John, love to have you back. And you brought us another great topic that was in the Thriving Urology Practice Facebook group. Do you want to tell us a little bit about the Thriving Urology Practice Facebook group and why it's so important?

[00:35] Dr. John Lin: Well, we've talked about this so many times, and if you aren't already a member of this free Facebook group where we talk about things like this, you're missing out. I'm not going to go into it again. Basically, just join. It's free. You're among colleagues in the United States, no vendors. Just join. It's going to help you in the long run. A lot of people tell me that it's the only reason they're on Facebook.

[01:02] Scott: Awesome. So definitely join. And John, thanks for joining us and thanks for bringing this to us. Do you want to get us started and share the topic?

[01:11] John: There's no shortage of questions in the Thriving Urology Practice Facebook group, where members will bring up anything and everything regarding the practice of urology. Fair warning to the listeners: this is essentially going to be a deep dive into Medicare Advantage plans, so hang on to your seat. The question comes from a member of the Thriving Urology Practice Facebook group, and the title goes something like this: We are out of network with UnitedHealthcare Medicare Advantage plans, henceforth also referred to as Medicare Disadvantage and Medicare replacement plans by me. They sent a letter recently informing us that they are narrowing their provider network. Now they are calling us back asking if we can please see their Medicare Disadvantage plan PPO patients with out-of-network benefits. The patients have a $25 copay, a deductible, and then UnitedHealthcare would pay the rest. I told them we're not contracted in network, therefore we'll be billing out of network. UnitedHealthcare said they have an allowed amount for out of network, but they will not tell us what the amount is. So we are at an impasse. There's no way I would do a procedure or surgery or administer advanced chemo for prostate or bladder cancer if I had a suspicion that UnitedHealthcare would way underpay for our services. We would literally lose money to provide services. I don't have the resources to fight with them. Any thoughts here, aside from saying good riddance to UnitedHealthcare Medicare Disadvantage plans? I have a lot of their legacy patients that I have been seeing over the years. What do you think, Mark? So much to discuss here.

Keep your contract with the patient

[02:54] Mark Painter: Yeah. I'm going to go with the short answer first, which is: you've already said goodbye to United. Stay that way. To me, the easy solution is continue to bill the patient and let the patient bill United. You don't have a contract. You're not stuck with a contract. Your contract is with the patient. The patient's the one with the contract with United. They can bill United. In the end, I think you can continue functioning as you have. You've already gotten rid of United; stay that way. Ignore their letters.

[03:33] Scott: But I was going to say that puts a lot on the patient.

[03:38] Mark: It does. But you're out of network. You're going cash with those patients anyway. So essentially there's not really a change for what you're doing; you're just sticking with your contract with the patient. Let them know they can file with United, they can play the lottery with United and figure out how much they're going to get reimbursed on the out-of-network benefit. And that United's been far too burdensome with their rules and regulations, and unfortunately because of that you have ceased contracting with UnitedHealthcare. I'm happy to see you, but I'm contracting with you. My arrangement is with you, the patient. We can keep our relationship. I'd love to see you, but this is the way we want to do it.

[04:29] John: So he has a lot of legacy patients, and they're just going to be seen as out of network. And when it comes to out of network, you can either play the lottery with what UnitedHealthcare may or may not pay you, and you may or may not be made whole depending on the service you provide. Or, on the other hand, you would just say it's the patient's responsibility for our fee schedule, whatever our fee schedule is, and then they can submit the bill or the claim to the UnitedHealthcare Medicare replacement plan and see how much they get paid.

[05:04] Mark: Yeah, and see what they get back. Full disclosure, all those things are there. And of course, I think the real caution you've got is if you break down with one patient and it hits the patient network, which it does, somebody else is going to ask too. So in the end, it's a commitment to remaining truly out of network and staying contracted with your patients that want to stay with you. If they don't, then they can go somewhere else to get their care. I know that's kind of callous with the way things are these days, but I don't know that you've got a better response.

The pitfall of billing the plan, and how to set a cash rate

[05:47] John: So what is the pitfall that practices must watch out for if they are nice and the practice simply bills UnitedHealthcare and just takes that as payment in full?

[06:03] Mark: The majority of United's responses to out of network, and I think a lot of this came down with the No Surprises Act, is that the payers will typically treat an out-of-network patient under their fee schedules one way or another, either a partial or full payment on the network rate. Ultimately you can go through arbitration with them and argue as to what they would like to pay, but you're probably stuck with something fairly close to, if not on, a network rate. So essentially it would put you in network in your first reimbursement when you play that game. If they really want you to see their patients, then they should come back to the table and give you a network rate that you can accept. Otherwise, again, keep your contract with the patient and don't play that game.

[07:12] Scott: So how does that discussion go when you're in there with the patient, or when your admin team is having that discussion with the patient, and how do you set your rate at that point?

[07:24] Mark: My recommendation for a lot of these folks is, number one, you clearly explain you're not in network with that particular payer, and you are happy to give the patient a copy of the bill so they can file for any out-of-network benefits on their own. We have a set rate; our rate is X. As far as setting your rate, a lot of it depends on your patient base, but I do encourage you to look at a rate that is fair to you, whether it's two times Medicare or 150 percent of Medicare as your starting rate. Those are just numbers that I pulled out. I'm not telling you what to charge. You should charge what you think is fair in the marketplace. But I do encourage folks, if they are going to do this, to have an incentive plan in place to get payment prior. Maybe you set that overall rate at one rate and then offer a discount if they pay up front in full, or a partial discount if a percentage gets paid up front and they don't want to pay the whole thing. So you're retail now. This is where you have to understand your patient base and what motivates them, because that's a cash transaction, and your staff does not have the option to bill the insurance company on the patient's behalf. It's just a standard rule. This is a cash transaction between you and the patient, and that's the way it needs to work.

[09:20] John: Should practices consider using an ABN?

[09:25] Mark: I don't see a reason in this case to use an ABN. You're not bound by a contract. Now, if you have a contract with United somewhere else where you may have some silent TPA in there, then you would probably get an ABN just to be safe, if there's any question of some hook somewhere within your relationships with the other payers. That's where I'd put in the ABN. But if you're clearly out of network with United, and there are no ties in any of your IPAs or any of your hospital-based negotiated networks, then there's no reason for an ABN. It always boils down to knowing your contracts and understanding all of them, because United is ubiquitous, it is absolutely everywhere, and there are tons of silent TPAs. If you know your practice and you've got no hooks, don't worry about it. If there's a potential of a hook, then go ahead and have them sign an ABN. But I would have them sign a financial agreement either way, because you want a binding contract. In fact, there are some states, like California, where if you don't have that agreement signed up front, you can't bill the patient. Legally, they can walk away from the bill. So you also need to understand your state's rules and regulations.

Traditional Medicare versus Medicare Advantage

[10:59] John: And in California, you can't report that to a financial institution, so it won't hit the credit of the patient who doesn't want to pay you. Mark, at the Urology Advanced Coding and Reimbursement Seminars every year we get these questions, which tells me that attendees don't quite understand what Medicare Advantage is versus traditional Medicare. Medicare Advantage, also known as Medicare replacement, also known as Medicare Part C. I affectionately call it Medicare Disadvantage. Can you tell us the distinction between traditional Medicare and Medicare Advantage?

[11:35] Mark: First of all, I don't know if your term Medicare Disadvantage is affectionate.

[11:41] John: It's a special place in my heart.

[11:42] Mark: Yeah. Every patient that is on Medicare Advantage is eligible for Medicare by definition, because that is part of the program. So the patient has the opportunity to be either in traditional Medicare or in a Medicare Advantage plan. Now, these have two different names within the CMS family. We know that we have Medicare Part A, which typically pays for inpatient services, skilled nursing facilities, those types of things, and that's part of the Social Security trust fund. It's funded very differently than everything else, and that's the one everybody's keeping an eye on to see if it's going to go broke, because we don't have enough young people filling the bucket and we've got a bunch of us boomers, and I'm barely a boomer, draining the trust fund because we're living too long. That wasn't the expectation in the very beginning. So that's Part A.

Then Part B, which is primarily funded as we go with premiums and some other taxes, where we're not really worried about the long-term health of the fund. Obviously we are worried about the fact that Medicare hasn't actually raised physician rates since 2013, so there's a different problem we're dealing with in Medicare Part B, and that's also where ambulatory surgical centers and HOPDs get paid from. But Medicare Disadvantage is Medicare Part C. If a patient moves from the traditional Medicare plan and Part B to Medicare Part C, essentially we don't have the same rules that apply. We do have under Medicare Part C a requirement that the Medicare Advantage plans offer at least what Part B Medicare offers, but they can layer on things like a spending allowance or a gym membership or all the other things you see on late night TV that are above and beyond what Medicare Part B offers. But they are essentially moved from one program to another. Therefore, there is no reason to worry about the ABN that would normally be applied in Part B when you're dealing with these circumstances, because that patient is not in Part B; they are in Part C.

[14:35] John: I think what people need to understand is there's traditional Medicare and Medicare Advantage. Traditional Medicare is Part A and Part B, and Medicare Advantage is essentially Medicare Part C. Medicare Part C can cover both A and B. But what the practices and the patients need to understand, and often we don't, is that Medicare Advantage is essentially a private insurance plan. It's a plan that is being administered by private insurance. So I tell patients, once you sign up for a Medicare Advantage plan, you're no longer in traditional Medicare. We're dealing with a private insurance company. Although Medicare Advantage plans have to cover what Medicare Part B covers as far as services go, they can layer on not just perks, such as dental coverage, vision coverage, maybe a spending card, maybe a gym membership, but also, for the doctor's offices and urology offices, it comes with additional burden and headaches, like prior authorizations and further limits in participation. In this question, UnitedHealthcare decided to divest themselves from a lot of hospitals and urology practices. Now they're coming back wanting their PPO patients seen. So yes, there are some advantages to the patient as far as perks, but that means more work and more headache for the doctor's offices. And just like a private insurance plan, you can decide to participate with a Medicare replacement plan or you can stay out of network.

Narrowing networks and the access-to-care funnel

[16:24] Mark: Yeah, and I wanted to add, in the Part C world, we just had an announcement from Medicare that they will be giving Medicare Advantage plans a 0.0004 percent raise. So essentially no raise, when every one of those plans was actuarially predicting a 4 percent bump in their fees, because they are supplemented by Medicare and technically paid more per service than what a physician is, to be the administrator on top of that plan. So I would expect, with United's response of narrowing the network and losing physicians and hospitals around the country, and the cuts in the Medicaid programs that have occurred recently, that you'll see a lot of these Medicare Advantage plans choose the narrower network for their services, and the generosity of the out-of-network benefits will match what they're doing in network as much as they can, to try to control their cost.

Their goal, and this is one of those things we've talked about a number of times in the Urology Advanced Coding and Reimbursement Seminar, is that you have to look at access to care like a funnel. If you narrow the network, you close the opening of how many people can enter the system, and that means people spill out the top, and they're perfectly happy with patients spending out of pocket to access care because they can't get what they want, or they can't get the services as soon as they want. The other piece I'll add is that a lot of these network plans, in the way they've changed the star rating system, have potentially given up on the pursuit of the five-star program that requires the patient to actually stay within network, and let patients hop from plan to plan. So between these two things, it is going to be more difficult to play with Medicare Advantage plans, and the one vote you have as a physician on the Medicare Advantage plan that's immediately effective is going out of network. Don't sign the contract. I appreciate what that practice has done. They made a choice, and I would encourage them to keep that choice.

What Dr. Lin does with Medicare Advantage in his own practice

[19:24] Scott: John, what have you decided to do with the Medicare Advantage plans in your practice?

[19:29] John: We decided not to participate with most of them, because of all the administrative headaches, or administrivia, as Mark would say. A lot more work for no additional pay or minimal additional payment. Why would anybody do that? It just does not make sense.

[19:50] Scott: I was going to say, I know you do a lot of cash pay business with your vasectomies, but this is a different beast when you're talking about out of network in a Medicare plan. Do you have any experience with that? Have you experienced this specific scenario, and what have you done about it?

[20:11] John: Yeah. By staying out of network, patients still need care. Just last week I saw someone who is a winter visitor, also known as the other white meat, a snowbird, who came from Canada, and he's happy to pay cash. So that's one instance. Just like Medicare, someone on a Medicare replacement plan, if he or she needs care urgently, they're going to want to sign up for, hey, just take care of my UTI, take care of my kidney stone, whatever. So it's unfortunate for the patient, but that is the choice he or she made when they signed up for a Medicare replacement plan.

The problem is the deceptive sales tactics by brokers and salespeople of these Medicare replacement plans. As you mentioned, Mark, at the very beginning, late night television commercials by these Medicare replacement plans, celebrity endorsements by Joe Namath: hey, this is great, you get free dental, free vision. Well, just like Obamacare, just because you have insurance doesn't mean you're going to get care. Mark, you said the top of the funnel and the bottom of the funnel. Being on a replacement plan, you're limiting the top of the funnel. In addition, by limiting the number of providers who can see these Medicare replacement plan members in a PPO or HMO plan, and forget about the HMO, the network is even narrower, you're limiting the bottom of the funnel. You get spillover, like you said. So patient, just because you have insurance like a Medicare replacement plan doesn't mean you're going to be able to get in to a doctor. And that's why United and other Medicare replacement plan administrators and insurers are having to beg, having to justify that, hey, we deserve to exist because we have a panel of doctors who are willing to see these patients. Without the doctors, there's no plan. So there's your leverage.

[22:14] Mark: Yeah. And remember, the numbers do not lie. We do have a law of supply and demand. It's not really fully applicable in healthcare because we've got too many people with their fingers in the pie. But we're going to be short 3,500 urologists in the next eight years, and it's going to be a slow decline as some of the urologists out there retire and we're just not replacing them fast enough. And again, that boomer wave that's coming in that needs urology care is going to increase the need. So there is something you can do, if you want to march with your pen, if you will, and put it in your pocket.

[23:04] John: Yeah. So what's been happening with UnitedHealthcare, which made them narrow their networks late last year? Like Mark said, they did not get the anticipated increase from CMS for 2026. So not just UnitedHealthcare, but a lot of the Medicare replacement plan insurers have narrowed their network. Basically they're divesting themselves from the book of business that is less profitable. So tens, and probably hundreds of thousands, of Medicare replacement plan members, their plans just ceased to exist, so now they have to scramble to find replacement insurance, whether that is to get back to traditional Medicare plus buying a supplement, or finding another Medicare replacement plan. We need to remember that the purpose of all these private payers is not to serve you, the docs, not to serve the patients, but to make a profit for their stockholders. So understand their incentive, and then you understand why they do certain things.

You control the contracts you sign

[24:11] Scott: Yeah, and to re-emphasize what you both have said: if you're a urologist out there, you are in control to make your decisions on what contracts you sign and what patients you see. There's not a shortage of patients in the country. I guess in your area you need to pay attention to that and what makes sense for you and what your patient mix is. But the real power lies in that contract, and what you decide to do and how you decide to do that. As we talked about earlier, John, you made a decision, I think, a few years ago and got rid of some of your big payers and really focused on what you wanted to do and how you wanted to do it. And from what we've heard over the last few years, that's a happier place to practice too.

[25:07] John: Oh my gosh, yeah. The thing is, you have to remember that you have control over your destiny. For some of you who are employed and your employer is dealing with your insurance, your book of business when it comes to insurance, you may not have any control, but that's a totally different discussion, whether you should be an employee versus a private practice doc. That is really up to you. Some of you need to stay at a certain location because your in-laws are there, your family's there. It's a choice. Everything that we do is a choice. Whether to participate with a particular payer is also a choice. We got rid of Blue Cross Blue Shield of Arizona many years ago, because they're the worst payer and they also mandate the biggest headache when it comes to trying to verify insurance, verifying benefits and stuff like that. For less payment, why should I do more work just to see a member?

The other thing is, we have this biased thinking that patients are not going to want to pay out of pocket for the service that we provide. Well, just think about the watch you purchased, or maybe a purse you purchased recently. You paid the extra premium for whatever premium product you purchased. You spent the money because you saw the value of that product. Patients who won't pay for your services apparently don't see the value in your services. We will pay for what we value. That's the bottom line. And if the docs, the practices, don't value their services, nobody's going to value your services.

[26:59] Mark: So true. Now, I will add, in all this stuff, it is tough in the marketplace making these decisions. Some of the biases I run into as I talk to different groups about participating or not participating with different insurance companies are real, in that geography dictates that they play with these plans. They have patients that are choosing to spend their hard-earned money on their premiums, or they're choosing the Medicare Advantage plan because they need that spending money, whatever those choices are. If the majority of your patients play that game, then that makes it more difficult to go out of network. So you do have to really take a look at your market and where your competition is, and then make those decisions. It is easier to say this from our position. It doesn't make it any less true that the choices are there; it just makes all the considerations that much more important as you go through this.

It's a good thing for folks at this point in time that we have a number of physicians who are willing to follow the patient's choices and provide as much care as we do. But it is going to get more difficult, I think, to make those decisions. And it is a system that I think we would all agree is really broken. It is not serving the needs of anyone in the system to the full potential that it could, and that's for a lot of reasons. It's not all the insurance companies' fault. It's part of their fault; there's certainly a big piece of it. The government's a piece of it. Pharmaceuticals are a piece of it. Hospitals, private equity, everybody's got a piece of where we are in the system. It is a system that we have to live with, and it's a complex one, and there are multiple considerations that each person, each group, has to make to deal with their marketplace.

[29:32] John: Yeah. Before you drop an insurer, make sure you understand your patient demographic, and also make sure you know your numbers. If you decide to drop a particular payer, how much of an impact will that be? On the other hand, if you're seeing a lot of patients for this one payer who's paying you poorly, when you free up that schedule you're most likely going to be filling it with the better payers, because there's no shortage of patients. And here's the unintended consequence that you also need to understand. When you drop the worst payer in your practice, what may happen is that the surrounding practices will end up seeing those patients who had the insurance that you dropped. And if other practices drop that poor payer, you'll end up with more of the poor-paying patients. So you need to understand the corollary when things like that happen with your practice and also with practices around you.

Sponsors and closing thoughts

[30:38] Scott: Yeah, that's so true. All right, let's wind this episode up here and get some final thoughts. First, we want to thank ModMed for supporting this episode. If you're in the market for an EHR or a practice management system, you can go to modmed.com/prs for specials for our listening audience. Also, we want to make you aware of the PRS Coding and Reimbursement Hub. You can go to prsnetwork.com/urologyhub for access to information on treatment categories such as prostate biopsies and kidney stones, as well as to look at specific products that treat those particular disease processes. We also have a lot of great quick reference guides and calculators, our PRS CodeMatrix guides and calculators, that are available free of charge. Just go to the site and you'll see it at the top under Tools and CodeMatrix. All right, let's get some final thoughts. John, final thoughts.

[31:50] John: Medicare Advantage is a private payer wearing a Medicare costume, or, as I like to say, lipstick on a pig's face. You should follow Medicare rules with Medicare, not with insurers who won't even tell you what they'll pay. Remember, Medicare replacement, AKA Medicare Disadvantage, AKA Medicare Part C, AKA Medicare Advantage plans, are private insurance plans. Deal with them accordingly. They need you to allow them to have a provider network so they can justify their existence. Know your leverage, know your worth, and never shortchange yourself.

[32:29] Scott: Well said. All right, Mark, final thoughts.

[32:34] Mark: Know your practice on this one, and know your goals. That's part of understanding why you got into medicine, understanding your patients and your community, understanding your practice. The other part we did not talk about is that if you are out of network, you are dealing with patient collections. They're a tough payer. So you have to make sure that your personnel are capable of collecting cash to keep you in business. It really is about understanding everything that surrounds you within your practice: the capabilities, your demographics, your competition. So it is important to work through all of those things, and I would start with your goals. We've talked about the demand and supply curve in all of this. You have options. You need to decide what you want to do, how you want to do it, and then build the system around you to support you. And that includes the decision to participate or not with Medicare Advantage plans and the Part C program.

[33:49] Scott: So true. All right, that's all we have for today. Thank you all for listening. Take us out, John.

[33:58] John: Thank you for the privilege of your time. Take care of yourself and each other. Until next time, happy coding.

 PRS Coding and Reimbursement Hub

Access the Hub

Botox LCD Alert

Download the Alert

Free In-Office Prostate Biopsy Calculator (Suppoted by UC-Care)

Download Now

PRS Coding Courses

For Urologist

For APPs

For Coders, Billers, and Admins