Billing > Billing

out-of-network billing

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Pay_My_Claims:
ok, I still learn each day.............thats a good thing

DMK:
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:

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


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.

Pay_My_Claims:
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:
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.

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