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Thread Topic: Out of Network Payments
Topic Originator: Tracey
Post Date May 12, 2008 @ 10:22 AM
Out of Network Payments

May 12, 2008 @ 10:22 AM Reply  |  Email Friend   |  |Print  |  Top

We have just terminated our contract with BCBS/GA; how do you inform your patients the amount they are going to need to pay you in regards to surgical procedures?  

We are not sure what the allowables are going to be and we will be balance billing the patient.

steve verno
May 13, 2008 @ 2:55 PM Reply  |  Email Friend   |  |Print  |  Top

The best way is to incoporate this into your practice financial plan, which you  has a policy to send payment to a patient when the provider is non par.  You could collect 100% at the time of service.  YOu could also require the patient to send their own claim for reimbursement.  But that is up to you.

May 19, 2008 @ 2:42 PM Reply  |  Email Friend   |  |Print  |  Top

ok -- can we provide a Time of Service Discount (ex:  cash discount) and do we have to disclose that on the claim when we file it (as a courtesy) to the insurance company?

A little background on us -- we are a plastic surgery office and we do many cosmetic procedures and since BCBS cut our fees on our reconstructive procedures by 60-70% we chose to go out-of-network.  We are also the ONLY plastics office in the area so we are going to be seeing ALOT of Breast Reconstruction/Breast Reduction patients out of network and we are wanting to provide some kind of discount instead of balance billing $25M to the patient ( in some cases...).  This way we can at least provide the patient a monetary break when they are still choosing to use us.

I know -- sorry this got so long-winded!  :)

steve verno
May 19, 2008 @ 5:18 PM Reply  |  Email Friend   |  |Print  |  Top

TOS discounts should not be used with patients who have insurance. IT should be used with uninsured patients. What you are doing is telling the insurance company you are not contracted with, that you agree to be paid less than your usual and custmary charges. This allows the insurance company to pay you their low reimbursemen fee.  In addition, this hurts my provider because now the insurance company tells my provider he charges more than other providers. It makes it harder for my provider to get a decent contract reimbursement when they say all we pay providers is $x.xx.

Be careful that the insurane company doesnt come back and state your discounts are costing them revenue because the patient may have a $200 deductible and if you gave the patient a 50% discount on the deductible, the insurance company could say that he premiums for he patient could be $100 per month more to have a lesser deductible.  

Last, with insurance companis with Federal Contracts, the insurance company could say you might be misrepresenting your true charges because all you are collectin is #X,XX.  instead of $y.yy.

May 20, 2008 @ 9:57 AM Reply  |  Email Friend   |  |Print  |  Top

ok - here is an example.  Humana; we are out of network.  Patient chose to still use us for Breast Reconstruction.   After filing charges to Humana ($17.5M); they paid (drumroll please) $1299.10!  It states on the EOB that patient responsibility is $15M!  How can we possibly bill the patient that amount?  This is just her first stage surgery -- she has 2 more to go.  Can we provide some form of a discount or incentive to the patient on the remaining balance...we would be giving a discount if we were an in-network provider but not quite THAT much of a discount.  

Just to make it clear -- Our charges are the same -- we bill everyone the same amount...even our cosmetic patients.  Our charges are in line and are not inflated.  Yes, I agree with you and that is why our insurance companies are slicing, butchering our allowable schedules.  As far as UCR -- it doesn't seem to exist anymore!  125% of medicare by some insurance companies is what they are considering UCR!  That is unacceptable!  

Thank you so much for your just frustrates me that insurance companies get away with paying so little, charging so much and CEOs growing richer!

steve verno
May 20, 2008 @ 5:57 PM Reply  |  Email Friend   |  |Print  |  Top

Did i read right that the charges were 17 MILLION???

Jut because an insurance company paid their fee, doesnt mean that amount is correctr. This is where the member must appeal the benefit payment. iT may be possible that the benefit is to be paid at 100%.

steve verno
May 20, 2008 @ 6:11 PM Reply  |  Email Friend   |  |Print  |  Top

I think you meant 17 thousand.  

Also, if this was a Humana Medicare HMO plan, all you are entitled to receive is the Medicare allowable amount.  The patient may not be responsible for the unpaid balance.

If this is not a medicare HMO plan, the plan may require the insurance company to pay 100% of charges.  The following is from a Humana ERISA Benefit plan:

The amount of plan coverage is usually 100% after the payment of annualdeductibles and co-payments.

If this patient has the same plan, then  Humana should have paid 100% less any deductible amount and the member must appeal, not you.  

The following is from the same Humana Benefti Manual:

If a claim is denied in whole or in part, an individual must receive a writtenexplanation of the reason for the denial. He or she has the right to have thePlan Administrator review and reconsider the claim. Under ERISA, there aresteps an individual can take to enforce these rights. For instance, if anindividual requests certain materials from the Plan and does not receive themwithin 30 days, he or she may file suit. In such a case, the court may requirethe Plan Administrator to provide the materials and pay the individual up to $100 a day until he or she receives the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator.

May 21, 2008 @ 11:02 AM Reply  |  Email Friend   |  |Print  |  Top

YES!  $17,500 --- (I have a banking background and M means Thousand and MM means Million in that world) ---  
This is for a non-medicare Humana HMO.  This is a Humana PPO plan.

Anyway, how can we 'assist' the patient in the appeals process?  Usually, these patients do not understand their own plan let alone writing an appeal letter.  I have a hard enough time explaining to them the allowable vs charges vs what they owe...I hate to bill them that amount and then say oh well, it's up to you to get your insurance to pay more money.  We would still be the one losing out!

steve verno
May 21, 2008 @ 5:30 PM Reply  |  Email Friend   |  |Print  |  Top

If this PPO plan is an ERISA plan, Federal Law requires the patient to appeal this.  I understand how you feel, but Federal law 29 CFR 2560.503-1 requiress this. If you wish to help the patient you need their written permission to do so.  YOu also need to get a copy of their benefit manual to check their benefits an the appeals process.

May 21, 2008 @ 5:36 PM Reply  |  Email Friend   |  |Print  |  Top

I think your patients need to know all the consequences of visiting a non par provider.. Refer them to their benefits manual or ask them to discuss with their insurance rep before they visit you(or do it for them). They also have the choice to pay your discounted fees for uninsured patients and in that case no need to involve their insurance company.

May 22, 2008 @ 11:54 AM Reply  |  Email Friend   |  |Print  |  Top

Thank you so much for your responses!  

We do try to explain to the patients the extra costs involved with an out of network physician but they insist on coming to see our doctor.  Again, since he is the only one in 50 mile radius I can sympathize with someone not wanting to drive all those extra miles...

If we do see them and provide them our charges with a discount but state to them this would not be filed with their insurance company - is that ok?  What if they insist on filing claims and want the information to file?  Can we refuse to provide CPT and ICD-9 since it we agreed upon a lesser payment because we are non-par?

May 22, 2008 @ 3:34 PM Reply  |  Email Friend   |  |Print  |  Top


Ask your attorney if that kind of agreement is feasible. An attorney who specialized in health insurance law such as ERISA, COBRA or HIPAA would be able to tell you.

If you have many patients coming in with a kind of insurance, contracting with that insurance is maybe another option.

I wish you luck in finding a good solution.

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