Possible Termination of Participation Status

DOCUMENT   OVERVIEW:      This   document  may   be   used  as   a   tool   in   reimbursement   negotiations  
between   practices   and   participating   insurance   companies.      
[inside   address]  
Dear   [name]:  
The   principals   of   [name   of   practice]   have   met  to   discuss   the   group’s   continued   participation  
with   [name   of   insurance   company].    
It  is   our   consensus   that  [name   of   practice]   can   no   longer   continue   to   participate   with   [name   of  
insurance   company]   under   the   current  reimbursement  schedule.   While   we   beilieve   this   is  
unfortunate   for   all   parties,   to   do   so   will   ultimately   jeopardize   the   quality-­‐ of-­‐ care   standards   that  
[name   of   practice]   has   established.  
If   [name   of   insurance   company]   is   interested   in   discussing   the   above   matter,   please   contact  me  
at  [telephone   number].  
Otherwise,   this   letter   will   serve   as   official   notice   of   the   cancellation   of   our   participation  
agreement  with   [name   of   insurance   company]   effective   [date].   After   this   date,   we   will   be   happy  
to   see   [name   of   insurance   company]   patients   out-­‐ of-­‐ network.  
[name],   MD