General Category > General Questions
Out Of Network Surgery Claims
rdmoore2003:
I have to put my 2 cents in on this. If the proof of past full payments cannot be produced, this is a RED FLAG and I do not believe this true unless their is some unethical practices going on. Is this provider choosing to be out of network with all insurances or just these couple? Do you call insurance companies prior to services to get the out of network benefits?
With out of network companies, you have the right to have the patient to pay for services prior to the service. You can then file the insurance and based on EOB, you may have to refund some moneys but at least you have your money up front.
The way I am understanding how this provider is, he/she has ABSOLUTELY no clue of what he/she is talking about. My advise to you is to have a notebook and document EVERYTHING you do and what the provider says and does, (no patient information of course). You could be liable for anything that comes down the line from your lady prior to you.
Also, if providers that are out of network, got insurance payments in full, there would be no reason to have in network benefits/out of network benefits. Common Sense people.
PippiT:
--- Quote from: rdmoore2003 on January 08, 2016, 12:58:47 PM ---I have to put my 2 cents in on this. If the proof of past full payments cannot be produced, this is a RED FLAG and I do not believe this true unless their is some unethical practices going on. Is this provider choosing to be out of network with all insurances or just these couple? Do you call insurance companies prior to services to get the out of network benefits?
With out of network companies, you have the right to have the patient to pay for services prior to the service. You can then file the insurance and based on EOB, you may have to refund some moneys but at least you have your money up front.
The way I am understanding how this provider is, he/she has ABSOLUTELY no clue of what he/she is talking about. My advise to you is to have a notebook and document EVERYTHING you do and what the provider says and does, (no patient information of course). You could be liable for anything that comes down the line from your lady prior to you.
Also, if providers that are out of network, got insurance payments in full, there would be no reason to have in network benefits/out of network benefits. Common Sense people.
--- End quote ---
EXACTLY on the last line! That is my take on it. We are in network for a couple of insurances. I do not know why they are not in network for all. I have started wondering if he was using my inexperience to try to argue more.
I do call the patients insurance to verify benefits and get in and out of network surgery benefits. If surgery is scheduled I also get pre-auth etc. I don't believe anything unethical is going on. He is very good at detailing everything he does and bills. I just think somewhere he got in his head that the billed amount should be the allowed amount. They've been in business for a long time so I am the only one with very little knowledge.
The notebook is a good idea. Thank you for your two cents!!
PMRNC:
--- Quote ---He won't let me appeal. I just have to keep running in circles.
--- End quote ---
Ok, so you are DONE.. he won't let you appeal, won't let you bill patient. There's nothing further that can be done. Have you thought about going to them and telling them it's more beneficial to be in-network? With an ASC, you stand a much better chance of higher reimbursement from the insurance company than asking the patient for THOUSANDS of dollars up front.
On a side note.. you said the providers were par the ASC is not.. are you guys making sure the providers are informing patients of this? Why are IN network providers even referring to an OUT of network ASC? No one has asked that yet.
kristin:
I wrote a long reply to this post, and ended up deleting it accidentally. I see that many of the things I addressed in my deleted post have been addressed by others. Such as, if a provider thinks the billed amount is the allowed amount, why would any provider be in network, and why are patients being treated at an out of network ASC if the surgeon is in network and do the patients know this ahead of time, and finally, why does the provider think what they billed should be the allowed amount, and who gave them that information, which is incorrect?
Bottom line,the OP is between a rock and hard place, which is even worse when the OP is not an experienced biller. It looks like a few claims were processed incorrectly at full billed amounts, leading the provider to think that all claims should be processed that way, and when the provider says no appeals can be done, nor can the patient be billed, what is left as a recourse?
To the OP, my suggestion is to go to to the websites of each insurance company the provider is questioning payment on, and print off their policy on out of network benefits. Most, if not all, will clearly state how they will pay to OON providers. Which generally includes UNC rates, how they are applied, etc.
Questhrr.com:
Hello PipiT,
I can concur that everything people are saying here is true. Howbeit, I also am fully aware of tactics used by UHC and Viant, whereas, they are not fully paying what the members' policy requires.
It is true that this provider seems to have unrealistic expectations, however, there may be more reimbursements which he can recover. If you wish to point him to my services, you can direct him to my website at www.questhrr.com.
Thanks,
Kevin
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