Author Topic: out-of-network billing  (Read 6041 times)

gderilus

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out-of-network billing
« 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

 

Pay_My_Claims

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Re: out-of-network billing
« Reply #1 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.

blhoffman

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Re: out-of-network billing
« Reply #2 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.

Pay_My_Claims

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Re: out-of-network billing
« Reply #3 on: April 24, 2010, 05:29:09 AM »
Yes B, and whenever possible COLLECT UP FRONT!! It eliminates so much on the back end.

Michele

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Re: out-of-network billing
« Reply #4 on: April 25, 2010, 07:03:49 PM »
Don't forget, not all policies have out of network benefits, so sometimes payment is $0.
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blhoffman

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Re: out-of-network billing
« Reply #5 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

ssherman

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Re: out-of-network billing
« Reply #6 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.

Pay_My_Claims

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Re: out-of-network billing
« Reply #7 on: April 26, 2010, 04:11:00 PM »
the client receives more money????? client as in the provider??

ssherman

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Re: out-of-network billing
« Reply #8 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.

Pay_My_Claims

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Re: out-of-network billing
« Reply #9 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!!

ssherman

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Re: out-of-network billing
« Reply #10 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.

DMK

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Re: out-of-network billing
« Reply #11 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.

Pay_My_Claims

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Re: out-of-network billing
« Reply #12 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.

ssherman

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Re: out-of-network billing
« Reply #13 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.

Michele

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Re: out-of-network billing
« Reply #14 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.
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