DOCUMENT OVERVIEW: This document may be used as a tool in reimbursement negotiations
between practices and participating insurance companies.
[date]
[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.
Sincerely,
[name], MD