By Martine G. Brousse (not AI!)
"The Medical Bill Whisperer"™
Patient Advocate, Certified Mediator
AdvimedPro
December 27, 2024
Watch the video: https://youtu.be/TXjn5syXueM
More and more often, medical providers refuse to deal with insurance companies. They hold no contract or financial agreements, and bill their patients directly. Can you force your insurance plan to cover these Out Of Network (“OON”) services at the higher In Network rate? If yes, how?
A. What is a “Network”
· It is a fluid list of contracted medical providers who offer incentives when used.
· “In Network” means that the provider, whether be a professional (doctor or medical professional practicing for themselves, in a medical group or at medical center) or a facility (hospital, infusion center, skilled nursing facility, imaging center, etc) has agreed to accept lower allowances as “payment in full”. An “Allowance” is a contracted rate of payment for a specific service.
· Out Of Network ("OON") providers refuse such contracts. They have no financial
agreement with your insurance and are not even required to bill on your behalf. They do not
accept any allowance or payment from your insurance as “payment in full” but hold you
responsible for the full amount billed, whether you get any reimbursement back or not.
B. What it means for your wallet:
1. “In Network” providers offer financial incentives:
· discounts, higher insurance payments, lowest share of cost, most advantageous
benefits, in a word: the best way to save money, because you're using the terms of your
policy to your very best advantage.
· Your insurance cannot pay more and you pay less than by using In Network providers
2. “OON” services:
· If you must, or are using OON services, expect to be asked for the full fee, or at least a
deposit ahead of time or when services are rendered
· Because the provider does not offer discounts, even if your insurance pays something, the total balance will be at your charge
· Even if your plan pays anything at all, it will be much less than it would have paid for the same services at the In Network rate
· Your insurance may tell you that you have a maximum “out of network” share of cost, after which your insurance would pay 100% but this is not correct. Only 100% of a very
low allowance are credited, and that allowance seldom amounts to the full amount billed. That difference between what the provider bills and what the insurance “allows” is called “not covered” and is NOT credited toward your max liability. Hence, your Out of Network max is both unlimited and undetermined.
· Most of the medical debt out there, unexpected expenses, or what I call “desperation” care, is OON. When you really have no other ways of getting an In Network appointment
promptly or with the appropriate level of and must seek OON services, costs can rise
to significant levels really quickly.
C. Solutions
The federal No Surprise Act helps patients in two separate cases:
· Emergency hires: when you are in the ER or in the hospital following an ER admission,
even if you did not choose the facility nor hire consulting and treating medical professionals. In such cases, your insurance must pay all emergency services at the higher In Network
rate even if OON. The facility and medical providers must accept the In Network allowance
as “payment in full”, even though they might not be contracted. You cannot be billed for the
difference.
· Indirect hires at an In Network facility: if you receive services at an In Network facility (hospital, urgent care, infusion center, imaging center etc) by medical professionals such as Drs, pathologists, radiologists, surgeons or anesthesiologists who are OON, the law also
forces your insurance company to pay those OON providers at the In Network rate. Those
providers must accept that allowance as “payment in full” and are not allowed to bill you for the difference between the amount billed and the In Network rate.
2. National Networks
· Your policy may be also part of a national network that could force your insurance to pay OON providers at the In Network rate if that provider is contracted with the local plan of the State where services are rendered, but not in your State of residence.
· example: you receive medical services in Texas, and the provider is contracted with Blue Cross Blue Shield of Texas, but not with BCBS Illinois, where your plan was issued or where you reside. In such case, your services would still be processed and paid at the Texas In Network rate.
· Large insurance companies that offer plans over a large number of states (Aetna, Cigna, United Healthcare, Blue Cross/Blue Shield) all have national networks from which you may choose In Network providers when seeking care in other States, even if they are not listed in your own State.
· Some small insurance companies may buy into larger national networks (such as Multiplan) to provide their members with enough In Network options
3. No In Network provider
· You have gone through your insurance portal to locate an In Network specialist or facility, but could find no one able to provide the level of care, specialization, expertise, prompt appointment, or geographical proximity that you require. If you have no other or better choice than consult an OON provider, “Access to Care” mandates may help you.
· Some States and, some mandates at the federal level, can force insurance companies who cannot provide timely access to In Network providers must pay OON services at the higher In Network rate.
· If your current In Network provider cancels their contract, or if your new plan at the beginning of the year no longer shows that provider as contracted, but you must continue treating as transferring your care now would be deemed unsafe or threaten your health or outcome, you can apply for what is called Continuation Of Care. Federal law, again, will help support your right to have your new insurance or your current plan continue paying a now OON provider at the (previous) In Network rate. Your current medical provider should file a Continuation Of Care request to obtain a special authorization and guaranteed higher payment rates until your care can be safely transferred.
Conclusion
Although your insurance may tell you that OON services cannot be paid at the In Network rate, this is not correct. They are a number of instances where, either through legal mandates, through terms of policy, or through Access to Care requirements, your insurance can be forced to pay OON services at the In Network rate.
Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.
(424) 999 4705 - F (424) 226 1330
@martine brousse 2024 @ the medical bill whisperer 2024™
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