By Martine G. Brousse
"The Medical Bill Whisperer... and insurance stuff too"
Patient Advocate, Certified Mediator
AdvimedPro
8/11/23
You sought services from an out of network provider, who has no contract with your plan, and is not part of your insurance preferred “network”.
Can you still get reimbursed by your insurance?
Possibly! But 2 main conditions must apply: you plan offers out of network benefits and you must have the proper paperwork.
A. The Basics
There are 2 kinds of out of network charges:
· those that have been imposed on you
· those for services you wanted to receive,
The former does not fall under this blog.
The latter does.
B. The difference
1. Out of network claims that do NOT apply:
a) Services rendered under emergency conditions:
· These services are usually covered by insurance at a higher rate set under Federal and some States’ legal mandates
· This might include fees charged by an ambulance service, ER Doctor or Emergency Room, other professionals or hospital as a direct result of an emergency
· Charges are usually billed by the providers directly to your insurance
b) Services rendered at an In Network facility or hospital under normal circumstances but which you did not have control over.
· This might include fees charged by an anesthesiologist, assistant surgeon, lab, hospitalist (specialist at a hospital), radiologist etc
· Many States have specific laws forcing insurances to pay a higher rate to providers, who in turn must accept lower fees.
· Some plans may also offer extended coverage under such cases.
· Charges are usually billed by the providers directly to your insurance
2. Out of network claims that DO apply:
· You sought care knowingly & want to get reimbursed. This blog is for you.
· Services could be for specialists when none are available otherwise, for different types of therapists (Physical, speech, occupation, ABA), for mental health specialists, for certain facilities when an in network one has no bed, or does not offer the level or type of care you need.
· Because of delays in getting an immediate or prompt appointment, the lack of required expertise of similar In Network providers, your special medical or mental health needs, your remote location or specific referral by your main physician, you were forced to use an out of network option.
C. Proper paperwork
If your plan covers non-emergency out of network claims, you must provide complete and correct paperwork to get these charges processed and paid to you.
Invoices you receive from the provider of service will need to include the following:
1. Patient info
· Name, address and date of birth
· Diagnosis in the form of an ICD-10 code (the English description is not enough)
2. Provider info
· Name and credentials
· Contact info and address
· Tax ID#
· NPI #. This is the “National Provider Identification” number, which is unique to every medical professional in the US.
3. Services details
· Place of service code or description (office, hospital, home etc)
· Procedure code (called “CPT’ or “HCPCS” depending on what is it).
· English description of the service (i.e “Office visit”) is NOT enough
· Number of units per service. Certain codes/services are 1 per code (such as office visits) but other codes also have a time element. If one code is for 15 min, but the service lasted 45 min, then the code must indicate 3 units next to it.
It is the provider's responsibility, as part of their licensing requirements, to know how and to bill their services with proper codes.
D. Submission
1. Online upload
· With the info listed above, you are ready to upload your claim for reimbursement online through your insurance portal.
· You will need to include a copy of the invoice
· Add proof of your payment if you already took care of the bill and it is not indicated on the invoice (Venmo print out, cash receipt, credit card statement entry)
· Step by step instructions are usually easy to follow
· You should get an automatic confirmation of submission, on the portal or via email.
2. Fax, email or snail mail
· If going to older-fashioned way, make sure to include the insurance’s “reimbursement” or “patient claim” form to avoid delays or rejections
· This form is available online, or an insurance phone rep can (e)mail you one.
· The claims address can be found on the back of your insurance card
· Add proof of your payment if you already took care of the bill and it is not indicated on the invoice (Venmo print out, cash receipt, credit card statement entry)
· Check online or call your insurance after a couple of weeks to confirm receipt
Note: An invoice from the provider is good, a claim form (“CMS-1500”) is better as it could be automatically scanned into your insurance system and quickly processed.
Invoices must be inputted manually, and are too often wrong or mistaken rejected.
In Conclusion:
Too many offices and billing services balk at providing patients with the proper documentation. Many don’t even know what is needed to get a claim reimbursed… or may not care.
Do not let ignorance, incompetence or ill-will get in the way of you getting reimbursed!
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 2023
@ the medical bill whisperer 2023