Author Topic: out of network  (Read 5999 times)

laceyx08

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out of network
« on: October 05, 2011, 09:59:43 PM »
I'm new to this, so I don't really know how billing out of network works. Does the insurance company still give an allowed amount and pay a percentage of that, or do they pay a percentage of the full billed amount?

ascbiller

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Re: out of network
« Reply #1 on: October 05, 2011, 11:14:59 PM »
There are a few things that can happen and will be based on the patient's benefit plan.  Some plans do still calculate the allowed amounts based on full billed charges but not often.  The paid amounts will still be based on the allowed amount but how that amount is determined will vary.
Possible scenarios...

1) Usual & Customary/Reasonable & Customary (probably the most common)
The plan will then determine the allowed amount based supposedly on what similar providers in the area bill for the same for the same service.  Then apply the member's out of network benefit level, typically between 50-70% instead of the in network 80-100%.  Be prepared to appeal if the rate they determine to be usual, customary and reasonable is below what is expected.
2) MNRP
The plan will assess the allowed amount based on a Medicare-related fee schedule.  I think for most payers it is about 140% of Medicare currently.
3) Negotiate through a 3rd party vendor
In this scenario you would receive a request from the plan to reduce your fee & not balance bill the patient.  Not all plans offer and not all employers pay for what they call "shared savings".  If the payer uses this do not just accept the original offer as it may set a trend for the provider instead note that this is a one time agreement and negotiate for the best rate possible.  We have a formula based on location, procedure cost, and procedure type.

There are more payment methodologies being applied to out of network claims but these are the most common for my providers.  When verifying benefits initially most payers will state which method they use when they quote the benefit levels/coinsurance levels.  If they dont state it then ask how the pricing is determined for that carrier.  It is a good practice to track the payments you receive to ensure that your claims are being properly priced and processed accordingly. Good luck and be prepared to appeal.

laceyx08

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Re: out of network
« Reply #2 on: October 10, 2011, 07:30:35 PM »
if you are billing out of network, can you just submit the claim to them, or is there a process you have to do with each insurance company before hand? because i sent two claims to magellan for the same patient as out of network and they keep coming back denied saying tax id not found. the tax id is her ssn and its correct. i talked to someone at the insurance company and they said they dont have the provider in their system. so they made an account for her and said he will talk to the claims department and let me know where they stand tomorrow. is this something im going to have to go through for every insurance company we want to bill out of network to?

midwifebiller

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Re: out of network
« Reply #3 on: October 10, 2011, 07:38:27 PM »
We bill for many out-of-network providers. When we welcome a new provider, we immediately contact the major insurance companies in that area and "register" the provider's NPI with that company.  The insurance company needs to know that they are reimbursing a legitimate healthcare provider before they will cut a check. Aetna will not even speak to us about benefits without the provider being first registered.

Call Provider Relations, let them know you need to register an out-of-network provider with them so claims can process at the out-of-network rate.  You will need to say "out-of-network" several times, because they will think you are wanting to credential and contract with them.  For some companies, it is just a matter of faxing a W-9, others have a form to fill out and need the W-9 and license. We start with Aetna, UHC, Cigna and the local BCBS plan. It usually takes 4-6 weeks to register an NPI and all claims will need to be resubmitted after the provider is in their system.

I hope this information is helpful.
Kelli Sugihara, CPMB
Midwife Billing & Business, LLC
www.midwifebilling.com

rdmoore2003

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Re: out of network
« Reply #4 on: October 10, 2011, 07:39:28 PM »
If you do not have a contract with an insurance company, how would they know about you.  Some have programs to look up the provider information that you give them, but not all.   I have had some insurance companies that will add your provider right over the phone and some that you had to submit w-9, proof of insurance etc by mail and took up to 90 days.  All this just to add provider information in the system as out of network. 

Medical Billing Forum

Re: out of network
« Reply #4 on: October 10, 2011, 07:39:28 PM »

laceyx08

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Re: out of network
« Reply #5 on: October 10, 2011, 09:35:32 PM »
Ok thanks guys. I'm new to this and was under the impression that you could just submit a claim if you are out of network. Whoopsies.  :-[ 

DMK

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Re: out of network
« Reply #6 on: October 11, 2011, 01:05:29 PM »
You actually can just bill a claim, even if you're out of network.  You're going to get new insurance companies all the time.

Just understand that the insurance company will respond with a W-9 request, and/or a request for additional information.  You can file the claim (thereby making sure it's filed timely) and then call or go online and submit the providers information.  The claim payment will be a little slower as all the information is processed, but at least then the claim is in process. 

Don't procrastinate just because you're unsure.  You can find out where and when and how to file claims with a new insurance company fairly quickly!

Sophrosyne

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Re: out of network
« Reply #7 on: October 11, 2011, 02:17:07 PM »
As a side note, know that since your provider is not contracted with the insurance company, he/she is not required to write-off amounts above the insurance companies' allowable charge. In our office, our out-of-network patients pay us in full at the time of each visit. Then we bill their insurance* and the insurance pays the patient (if there is any payment to be made that is). This works well for us because in some cases, insurance companies will not make any payment to out-of-network providers.

*On the claim form we leave box 13 blank (indicating that the patient has not authorized the insurance company to pay us) and on box 27 select "No" (indicating that our provider does not accept assignment from that insurance company). This usually works although sometimes they pay us anyway and we have to send the check back with a letter telling them to send the money to the subscriber of the policy.

Medical Billing Forum

Re: out of network
« Reply #7 on: October 11, 2011, 02:17:07 PM »