Author Topic: out-of-network billing  (Read 5619 times)

Pay_My_Claims

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Re: out-of-network billing
« Reply #15 on: April 28, 2010, 02:49:15 PM »
ok, I still learn each day.............thats a good thing

DMK

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Re: out-of-network billing
« Reply #16 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.

PMRNC

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Re: out-of-network billing
« Reply #17 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.
Linda Walker
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Pay_My_Claims

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Re: out-of-network billing
« Reply #18 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)

DMK

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Re: out-of-network billing
« Reply #19 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.

PMRNC

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Re: out-of-network billing
« Reply #20 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.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
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Jdmontee

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Re: out-of-network billing
« Reply #21 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

PMRNC

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Re: out-of-network billing
« Reply #22 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.
Linda Walker
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One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Jdmontee

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Re: out-of-network billing
« Reply #23 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

PMRNC

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Re: out-of-network billing
« Reply #24 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)

Linda Walker
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One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Jdmontee

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Re: out-of-network billing
« Reply #25 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

DMK

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Re: out-of-network billing
« Reply #26 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

PMRNC

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Re: out-of-network billing
« Reply #27 on: May 24, 2010, 09:41:58 PM »
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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.
 
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

DMK

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Re: out-of-network billing
« Reply #28 on: May 25, 2010, 11:22:56 AM »
Thanks Linda! 

Zeecy

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Re: out-of-network billing
« Reply #29 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.