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out-of-network billing

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ssherman:
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:
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:

--- Quote from: ssherman on April 27, 2010, 01:21:37 AM ---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.

--- End 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.

ssherman:

--- 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.
--- End quote ---

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.
--- End quote ---

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:
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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