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Thread Topic: wrap-clause?
Topic Originator: Marianne
Post Date January 2, 2007 @ 10:44 AM
wrap-clause?


Marianne
January 2, 2007 @ 10:44 AM Reply  |  Email Friend   |  |Print  |  Top

Has anyone heard of a wrap-clause?  I am told that insurance companies that deny a claim due to being an out-of-network provider has what is known as a wrap-clause, in most insurance policies, where if more then 3 in-network providers are billing for the same of date of service (e.g. surgery) then all out-of-network providers will be covered.

Steve Verno
January 3, 2007 @ 11:05 AM Reply  |  Email Friend   |  |Print  |  Top

Never heard of it.  I have heard of a wrap around policy which is a supplementary insurance plan designed to pay for additional health benefits not covered by another plan.

A non-contracted provider is exactly that, a provider who has no contract with an insurance company and is not a party to any relationship regarding payment of health care benefits with that insurance company.  In other words, if the patient makes a freedom of choice decision to seek care from an out of network provider, than the patient must follow the guidelines in their contract with the health insurance company as to how to resolve the medical bills they incur.  You see, the insurance company has no obligation to pay your provider.  They have a contractual requirement to reimburse the patient for the medical expenses they incur.  If the insurance company sends payment to your provider, it is because the patient has asked the insurance company to take the payment of their benefit and send it to a designated person.  But many patient contracts states that the insurance company does not have to honor this request.  So, there is nothing that states that a non-contracted provider will be paid by the insurance company.

If you look at most patient benefit manuals, it is the patient that must resolve the medical bill with the provider, then send their own claim for reimbursement.

Leah
January 3, 2007 @ 7:48 PM Reply  |  Email Friend   |  |Print  |  Top

Marianne, when I had Aetna HMO, if I was hospitalized or had an ER visit, any providers that attended to me who weren't Aetna HMO providers would be paid their full fee without a balance owing by me.  This was also true the times I arrived via ambulance - my city is not an HMO provider but they were paid their full fee and I owed no balance.

However, I have never heard this being called a "wrap clause" and I don't think the number of providers is the criteria - many times it was only the ambulance and the ER docs, and some lab, usually only being a bedside BG.

I'm sure this only applies in emergency cases for any HMO and in inpatient situations where you can't pick your radiologist, pathologist, etc.

Does this help any?

Marianne
January 4, 2007 @ 8:40 AM Reply  |  Email Friend   |  |Print  |  Top

I, too, never heard of this wrap-clause but I do billing for 10 Surgical Assistants who are Non-solicitable providers with all insurance companies.  Needless, to say I always have to fight for their money.  An independent provider reimbursement specialist (so, she says) told me about this wrap-clause.
Thank you both for your reply.  I follow up on anything I hear that may help my clients get paid.

Steve verno
January 4, 2007 @ 1:01 PM Reply  |  Email Friend   |  |Print  |  Top

When someone tells you something that doesn't sound right or is something you never heard of, always ask them for their supporting documentation.  There are too many "so-called" experts out there that present information that is contrary to industry standards and when you confront these people and ask them to show you the supporting documentation, they can't.

As a non-contracted provider, you do have some choices when dealing with the patient and their insurance.  

1)  You can inform the non-contracted patient that they must pay for their care at the time of service and they can be reimbursed by their insurance company.  This is the best way to go but many people don't like it because they say they would rather send a claim and get some sort of payment from the insurance company.  Well, look at what you said, and I hear it all the time, "We have to fight to get our money from the insurance company "  This is because you are making a freedom of choice decision to do this and when you do, there are consequences of your actions.

2)  You can place the payment issue with the patient because this is their problem, which is to resolve their debt with you.  You aren't getting anywhere with the insurance simply because they don't have to answer to you.  What they paid may be all they are required to pay.  The balance may be the patient's responsibility to pay.  The right of appeal rests with the patient, not you.

So, how you want to resolve these claims issues is up to you.

Steve Verno
January 4, 2007 @ 1:21 PM Reply  |  Email Friend   |  |Print  |  Top

To add to what I just said, I hear all the time that asking a patient to pay, before they are seen, drives the patient away.  I tend to disagree on this but, it is true for those patients who will end up not wanting to pay their bills.  They will walk out and find a doctor who will not verify insurance, educate the patient on their financial requirements and demand payment at the time of service.

I have to have an MRI done tomorrow.  The MIR company just called me.  She contacted my insurance, they told her I have a deductible I must still meet and they know my health insurance will pay 80%, so they told me what I have to bring in tomorrow.  As someone who pays their medical bills, not just as a person that is a medical biller, I have no problems in paying what I owe.  Afyter all, if I am told I have a $15 co-pay or a $200 deductible, why should I complain about paying?

The people you meet who will intimidate you, become beligerent and yell and scream about paying are those who will not pay no matter what.  So, let them walk.  If I can pay my medical bills, and I am unemployed and money is tight with me, so can they.

Lucretia
April 2, 2008 @ 6:27 PM Reply  |  Email Friend   |  |Print  |  Top

a RAP-Clause is when a patient goes to an in-network facility and is treated by a physicain that is not part of their network, the insurance company will pay the claims at a higher level. so if your network was PHCS and the facility was contracted, but your Anesthesiologist was not. The physican would call the insurance and inform them that the facility is in network please reprocess the claim under the "RAP CLAUSE". You will be paid the in-network benfit and take a discount and bill the patient for what the insurance tells you is the patient balance.

Joann
June 8, 2012 @ 1:05 PM Reply  |  Email Friend   |  |Print  |  Top

Can you give provide me documentation or tell me were I can locate infromation on the wrap-clause.  I am currently fighting my insurance company to pay an out of network anesthesia bill. The surgen and facility is in network.

tj
June 10, 2013 @ 4:51 PM Reply  |  Email Friend   |  |Print  |  Top

it is a RAP clause or RAPLE clause. It stands for Radiology, Anesthesiology, Pathology, Lab & ER Doctors. These are ancillary providers that you cannot pick even @ a In Network Facility & with a Participating Surgeon. Most iinsurances have these clauses availalbe but it depends on the type of policy you have. Not all do, such as Self funded plans, unions, & governmental plans. You can call your insurance explain if you went to a Participating Surgeon & Facility that you do not have control over the ancillary providers @ that facility & they can confirm if you have this clause on your plan. Another clause to look for is balance billing clause, for the balalnce between the billed amount and the allowed amount that your insurance chooses that out of netwrk providers can bill you becasue they have no contractual obligation to adjust it off.



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