Medical Billing Forum

Billing => Billing => Topic started by: gderilus on April 23, 2010, 03:12:20 PM

Title: out-of-network billing
Post by: gderilus on April 23, 2010, 03:12:20 PM
I have a client that wants to bill out of network, don't providers get pay less when they bill out of network? She's a LMHC

This is what she asked me

" I've been researching other therapists and I see that many bill "out-of-network" so they don't have to become providers, and can work with any insurance company. It would allow us to take a lot more insurance clients".

I'm not sure what to tell her

 
Title: Re: out-of-network billing
Post by: Pay_My_Claims on April 23, 2010, 04:32:21 PM
Out of network means you get less money from the insurance company, but you can balance bill the patients. Being out of network has an advantage because you don't have to accept the rate that they pay, but most carriers want to negotiate it for the patient. They know that if you bill 1000, and they only allow 800, and in net is 80% out of net 50%, they pay you 400 (out of net) (subject to patient ded etc) you can bill the patient the 600 bucks. Now on the flip, if in network you would have gotten 640 from the ins company with the patient owing 160. unless you collect up front, out of network can mean more patient balances for the provider.
Title: Re: out-of-network billing
Post by: blhoffman on April 23, 2010, 11:16:55 PM
I agree with Pay_My_Claims, it is more patient billing ::)

I'm putting on my insurance/claims processing cap here with this statement. Many claims do come in for Out of Network in the area of LMHC. She is correct. Charlene hit the nail on the head. She isn't out money or paid less. She is just paid less from the insurance company but she does have the right then to collect the balance from the patient. This actually allows her to be paid for total billed amount, instead of a contracted rate.

I'm putting on my patient advocate/customer service hat now with this statement. Many many patient's do not understand the IN Network and Out of Network benefit, even today. Some know there is a difference and never ask. They just assume if they are accepted as a patient, see the doctor, therapist or whatever, they are in network. You have to make it abundantly clear to the patient you are not in network which would mean the patient is responsible for a large part of the bill, unless they have met their OON ded. or Out of Pocket Max.

That being said, there are patient's that are use to paying OON for this type of service in particular. I wouldn't let the fear of patient billing stop the practice from opening up to include OON billing. Just make this fact clear to the patient before services are rendered.
Title: Re: out-of-network billing
Post by: Pay_My_Claims on April 24, 2010, 05:29:09 AM
Yes B, and whenever possible COLLECT UP FRONT!! It eliminates so much on the back end.
Title: Re: out-of-network billing
Post by: Michele on April 25, 2010, 07:03:49 PM
Don't forget, not all policies have out of network benefits, so sometimes payment is $0.
Title: Re: out-of-network billing
Post by: blhoffman on April 25, 2010, 09:00:47 PM
Thanks Michelle!

That is correct. Be sure to ask what insurance they have and very benefits for OON before service.

Don't forget to COLLECT UP FRONT!!  ;D
Title: Re: out-of-network billing
Post by: ssherman on April 26, 2010, 11:38:24 AM
Billing out of network, the client receives more money.

Out of network means there is no agreement on the price paid for services rendered. Let the physician know that she should take a look at her fee schedule *first*, make any necessary adjustments, and then address protocol (as mentioned) for financial counseling for patients responsibility.
Title: Re: out-of-network billing
Post by: Pay_My_Claims on April 26, 2010, 04:11:00 PM
the client receives more money????? client as in the provider??
Title: Re: out-of-network billing
Post by: ssherman on April 26, 2010, 07:23:38 PM
Apologies!

The provider sees higher reimbursement at the cost of time/complexity. Billing in-network is pretty fast and straightforward (you are really enforcing pre-negotiated prices). However, out of network, you get to negotiate (within reason) on the value of services rendered.
Title: Re: out-of-network billing
Post by: Pay_My_Claims on April 26, 2010, 10:02:28 PM
Apologies!

The provider sees higher reimbursement at the cost of time/complexity. Billing in-network is pretty fast and straightforward (you are really enforcing pre-negotiated prices). However, out of network, you get to negotiate (within reason) on the value of services rendered.

YEAH they negotiate, but they don't pay more than they would in network!!
Title: Re: out-of-network billing
Post by: ssherman on April 26, 2010, 10:21:37 PM
Has that been your experience? The results I have seen indicate that OON reimbursement is generally greater than the in-network rate.

Of course the results vary by state and by insurer.
Title: Re: out-of-network billing
Post by: DMK on April 27, 2010, 01:20:20 PM
The other reason doctors and hospitals go out of network is that they can then make any deal they want with the patient.  They CAN just take the OON amount from the insurance company. If the IC pays 80% of U&C it's MUCH more than the contracted rate so the provider comes out ahead, and the patient will come back.  The provider can balance bill, but they should use the OON as a bargaining chip whenever possible.  It's good for business.  One of our local hospitals stopped all their contracts with insurance companies.  There business is still good because they can negotiate with the patients.  I've only heard good things so far, but I've definitely been listening for the complaints.

Thank you B for putting on the different caps.  It's important as billers to look out for your clients, but also realize that good patient retention is good business.  If a patient is happy, they're happy, but make them mad about money and they will tell everyone in town how badly they were treated, regardless if their care was good or not.
Title: Re: out-of-network billing
Post by: Pay_My_Claims on April 27, 2010, 03:39:00 PM
Has that been your experience? The results I have seen indicate that OON reimbursement is generally greater than the in-network rate.

Of course the results vary by state and by insurer.

why would they pay more ??? No, it has always been less, and we can't bill the patient the balance. They have a maximum they can offer u, sometimes it will be equal to the medicare allowable, but never more than what they would pay in net.
Title: Re: out-of-network billing
Post by: ssherman on April 27, 2010, 06:24:47 PM
Quote
why would they pay more  No, it has always been less, and we can't bill the patient the balance. They have a maximum they can offer u, sometimes it will be equal to the Medicare allowable, but never more than what they would pay in net.

My understanding is that a physician or facility will work with an insurance carrier for an in-network rate for various procedures provided and negotiate a reimbursement fee schedule. This fee schedule varies by physician as it is dependent on experience, services offered, locality (depth of market), and of course, negotiations. An in-network provider can also carve out specific procedures (and implants!) from the in-network rate to maximize overall reimbursement from the carrier (or for those specific high dollar procedures).

What this means is that there is no 'standard' in-network rate. There are probably general guidelines, but not a hard and fast rules.

Going in-network has the advantage of faster, simpler billing/collections and accessibility to a larger pool of patients- at the expense of lower reimbursement. It is more of a volume business model. Out of network is exactly the opposite.

If the out of network collections from the insurance is at or lower than the in-network reimbursement rate, then you are really getting the worst of both worlds.

Quote
The other reason doctors and hospitals go out of network is that they can then make any deal they want with the patient.  They CAN just take the OON amount from the insurance company. If the IC pays 80% of U&C it's MUCH more than the contracted rate so the provider comes out ahead, and the patient will come back.  The provider can balance bill, but they should use the OON as a bargaining chip whenever possible.

Agreed, however, a physician has to be careful in how they handle patient responsibility. There is a huge liability if insurance carriers discover that the physician is not following up on patient responsibility and is instead writing it off wholesale.
Title: Re: out-of-network billing
Post by: Michele on April 28, 2010, 06:53:18 AM
I have seen a few, although it is not the norm for my cases, where they pay a higher amount out of network.  Just a few.
Title: Re: out-of-network billing
Post by: Pay_My_Claims on April 28, 2010, 02:49:15 PM
ok, I still learn each day.............thats a good thing
Title: Re: out-of-network billing
Post by: DMK on April 28, 2010, 04:05:48 PM
I agree about the IC and patient responsibility.  The provider should have a policy in place so that the patient is informed ahead of time about what payment they will be expected to make.  I know it's illegal in CA to advertise No Out Of Pocket (NOOP).  But if the provider says up front that they accept U&C on out of network billing then that means REGARDLESS.  If they balance bill, then it's everyone.  You don't get to pick and choose.

Then there is always the sliding scale for low income.  When you're out of network you have way more flexibility but it should still be a policy that's IN PLACE.  When you're contracted you MUST collect the deductible and co-pay, no discounts, no writing off.
Title: Re: out-of-network billing
Post by: PMRNC on April 29, 2010, 05:28:30 PM
Quote
The other reason doctors and hospitals go out of network is that they can then make any deal they want with the patient.  They CAN just take the OON amount from the insurance company. If the IC pays 80% of U&C it's MUCH more than the contracted rate so the provider comes out ahead, and the patient will come back.  The provider can balance bill, but they should use the OON as a bargaining chip whenever possible.  It's good for business.  One of our local hospitals stopped all their contracts with insurance companies.  There business is still good because they can negotiate with the patients.  I've only heard good things so far, but I've definitely been listening for the complaints.


I'm coming into this late, but the above maybe what doctors INTERPRET, but they can not arbitrarily make deals with patients on balance, that is why OON plans are considered "Cost sharing" If the provider is negotiating balances after insurance routinely that is illegal and is fraud. The policy is a binding contract with cost-sharing provisions for a reason. If the doctor for example wants to waive 10% of the 20% coinsurance he needs to pass that discount ON to the carrier FIRST.   In billing we call that TWIPPING (Take what insurance pays) and it's fraud. If there is a necessity to cut / waive the patient's out of pocket there should be a financial hardship agreement on file.

Forgive me if I misunderstood.
Title: Re: out-of-network billing
Post by: Pay_My_Claims on April 29, 2010, 07:18:03 PM
Medicare sure frowns on that when you don't make an attempt to collect the 20% from the patient. This happens a lot in DME for large items. they will (discount it)
Title: Re: out-of-network billing
Post by: DMK on April 30, 2010, 11:54:48 AM
Thanks Linda,

TWIPPING is a new term for me, but I appreciate what it means. It's close to NOOP.  It means that the hospital in town is going to be in trouble before too long!  Is the law on this different in California?  I'll have to look into it.

If you're out of network, is the provider obligated to still abide by the patient's contract with the patient's insurance?  I'm asking out of curiosity as both a provider and patient.
Title: Re: out-of-network billing
Post by: PMRNC on April 30, 2010, 07:31:22 PM
Yes, providers have to do their part in upholding the contractual relationship between the policy holder and the insured/dependents. ie; any cost sharing.   So for example if the OON plan pays 80% of the first $2000 in Out of pocket expenses, the patient is responsible for their 20% (cost sharing) So if a provider discounts any service, he has to bill that with the discount to the insurance company. They are entitled to any discount just as the patient would be.
Title: Re: out-of-network billing
Post by: Jdmontee on May 22, 2010, 10:17:56 AM
Am I understanding from these posts that if a provider is out of network with an insurance, the provider can choose to accept the out of network payment as payment in full and not balance bill the patient?  Or can negotiate a reduced payment from the patient for anything the insurance does not cover???

Thanks!

Joanne
Title: Re: out-of-network billing
Post by: PMRNC on May 22, 2010, 10:38:09 AM
No, providers cannot routinely waive out of pocket nor enter into private contracts (verbal or otherwise) that would violate the patient's insurance policy of "cost sharing". So if a doctor is out of network with a carrier and bills $100 and they pay $80. The patient is legally responsible for the $20 and the provider is legally obligated to attempt and collect it.
Title: Re: out-of-network billing
Post by: Jdmontee on May 22, 2010, 11:35:37 AM
Ok, that's what I thought but the posts seem to go back and forth regarding what a doctor is obligated to in an out of network scenerio.  Bottom line...out of network...provider is obligated to balance bill patient for anything the EOB shows as patient responsibility correct?  Just want to be sure as I have one provider who is out of network with most insurances.  I onlyprovide claims billing for this provider and provider bills patient themselves for any balances.  I want to be able to provide accurate info to him to be sure HE is doing what is correct and legal on his end.

Thanks much!

Joanne
Title: Re: out-of-network billing
Post by: PMRNC on May 22, 2010, 02:40:58 PM
No, REGARDLESS of in/out of network:  Physicians can not routinely waive out-of pocket expenses. (PERIOD) So if you have a provider in network and a patient has $10 copay, the physician must make an attempt to collect that copay (OOP)
And likewise with coinsurance (OON)

Title: Re: out-of-network billing
Post by: Jdmontee on May 22, 2010, 02:56:32 PM
Ok, I understand the in network as all of my providers are in network and only see in network patients,  I just acquired this provider who is out of network with most insurances and I wanted the clarification regarding out of network. The previous posts to yours were a bit confusing.  Thanks for the clarification Linda :)

Thanks!

Joanne
Title: Re: out-of-network billing
Post by: DMK on May 24, 2010, 11:45:21 AM
I know I'm probably beating a dead horse, but Linda I would greatly appreciate your input on this.

A patient has surgery.  The hospital, surgeon and the lab are all in network.  The patient pays the deductible and/or co-pay per the insurance contract.  The anesthesiologist is out of network.  The eob comes back and the allowed amount for a participating provider is all that the anesthesiologist gets paid.  The U&C is considerably more.  Is the anesthesiologist LEGALLY OBLIGATED to collect the difference, or can they accept the allowed amount for a participating provider since everyone else involved in the procedure was in network, and the patient was not informed that they were out of network?

All of the anesthesiologists in our town went out of network so that they would be allowed to work at the one hospital in town who dropped all insurance except Medicare.

Thanks!  Dina
Title: Re: out-of-network billing
Post by: PMRNC on May 24, 2010, 09:41:58 PM
Quote
The U&C is considerably more.  Is the anesthesiologist LEGALLY OBLIGATED to collect the difference, or can they accept the allowed amount for a participating provider since everyone else involved in the procedure was in network, and the patient was not informed that they were out of network?

Anything over U&C/R&C is patient responsibility.. You can however ask the provider to send in an appeal.
 
Title: Re: out-of-network billing
Post by: DMK on May 25, 2010, 11:22:56 AM
Thanks Linda! 
Title: Re: out-of-network billing
Post by: Zeecy on June 09, 2010, 10:06:13 AM
From a patient's point of view... I try to avoid using doctors that are out of network.  It's just too complicated & I never know what the insurance will pay & I end up owing much more out of pocket than if I use a physician that is in network.  I guess that's logical, but I just thought you might want to keep that in mind before deciding how to do the billing.

What I'm trying to say is, unless I'm missing something, it might not be in the doctor's best interest as far as attracting patients goes.