General Category > General Questions
Out Of Network Surgery Claims
RichardP:
--- Quote from: PippiT on December 29, 2015, 02:39:48 PM ---They ... put the allowed amount of $1,365.27 to the patient's deductible. ... they have 70% out of network benefits, so my provider expects $10,570 from UHC.
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It sounds like you and your client could benefit from a voice to voice conversation. No carrier ever pays a percentage of what the provider bills. The carrier always pays a percentage of their allowed amount. The wording you are using tells me that either you have misunderstood what your client expects from you and the carrier(s), or your client is a new provider, unfamiliar with the ways of getting paid from insurance carriers.
Regardless of where the misunderstanding lies, the two of you need to come together on this understanding: insurance carriers only ever pay a percentage of their allowed amount (in this case, $1,365.27). And, yes - very often the carrier payment goes to the patient's deductible and not to the provider's pocket. So, often the full amount must be collected from the patient. Does your client expect you to verify the patient's ability to pay before he agrees to see them? If not, then this is not so much your problem as it is your client's.
An ethical out-of-network provider will make certain the patient fully understands exactly what dollar amount s/he could be responsible for - for the services to be provided - before they are provided. In this case, it sounds like the patient is responsible for the full charge (being out-of-network, your client is under no obligation to accept only 70% of what the patient's carrier will pay).
An out-of-network provider can charge their patients whatever they want to charge. Collecting that money is another matter entirely. Word-of-mouth can destroy a provider's reputation. So your client needs to proceed carefully here.
PMRNC:
I agree with the others, the carrier for out of network is only going to base their % of payment on their U&C fees. BUT that is not to say you can't collect more with an appeal. The good news is that out of network U&C can be appealed, sometimes more gets paid, sometimes not. Your appeal has to be based on some research though with appealing U&C charges.
Michele:
I agree with Linda & Richard. The only addition I have is that the provider really doesn't know what he's collected in the past? And is unrealistic in his expectations? Being an out of network surgeon puts the majority of the burden of cost onto the patient. Since he is out of network he has no contract with the insurance carrier which allows him to bill his full fee. That does not in any way mean the insurance carrier will allow his full fee and process claims according to his full fee. I used to work for an insurance carrier processing surgery claims. Out of network or in network were always subject to RNC (or U&C - same thing). We had some codes that were "hard data" meaning they had lots of data to back up their amount and they didn't budge, or "soft data" meaning they didn't have that much and they would negotiate the fee. It was my job to call the provider and try to come to an agreement somewhere between our RNC amount and their fee.
PippiT:
I have zero experience in medical billing. I got roped into the family business. I really like it but these out of networks are a pain. I really cannot wrap my brain around what exactly I am supposed to do. He won't let me appeal. I just have to keep running in circles.
The professionals are in network the ASC is out of network. Not sure if that makes any difference.
But yes, one example is he billed $27,300.00 the patient's plan in and out of network is 50%. $2,319.79 went to patients ded. and the plan paid $2,157.53. I have spoken with a supervisor and he said this is all the plan pays, we have a right to appeal but it is patient responsibility. My provider expects $13,650. He told me this is unacceptable.
So you can see my dilemma. It is impossible to get them to pay what he wants. He thinks because he is out of network that the billed amount is the allowed amount. What exactly I need is to be able to tell him what RichardP said above.
I asked for examples where they were able to get the out of network paid at what he wants an no one can produce them. There are two claims that a carrier paid the full billed amount. There was no calling on them, the claims were processed and paid timely. I have no idea why those two paid the billed amount but I guess that is why he thinks they should pay the full amount? I am not seasoned enough to know what I'm doing or how to explain to him that he is wrong.
PippiT:
--- Quote from: RichardP on January 07, 2016, 11:29:50 PM ---
--- Quote from: PippiT on December 29, 2015, 02:39:48 PM ---An ethical out-of-network provider will make certain the patient fully understands exactly what dollar amount s/he could be responsible for - for the services to be provided - before they are provided. In this case, it sounds like the patient is responsible for the full charge (being out-of-network, your client is under no obligation to accept only 70% of what the patient's carrier will pay).
An out-of-network provider can charge their patients whatever they want to charge. Collecting that money is another matter entirely. Word-of-mouth can destroy a provider's reputation. So your client needs to proceed carefully here.
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I completely agree with this. I have no idea what the doctor and the patient discuss, but I know to check with my insurance prior to any major surgery to see what kind of expenses I am responsible. What I don't understand is why do these out of network surgeries at the ASC when they should be done at the hospital. I'm not in his head so I can only surmise he has an unrealistic idea of how he should be paid.
The bottom line to him is that he does not have a contract and the billed amount is the allowed amount and that the insurance company needs to pay it. I've told him it is patient's responsibility per the ins. company and he says that is unacceptable. I feel like I've wasted a lot of time on these 4 claims.
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