Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

When Patients Are Out of Network


Recent news stories about patients’ astronomical out-of-network medical bills resulting from in-network hospital visits are highlighting once again the complexity of our health insurance system. While some critics bemoan narrow networks or accuse physicians of over-charging out-of-network patients who had no choice, physicians, like patients, find themselves in a difficult position to negotiate, especially when narrow networks and government payers are forcing physicians to accept below-market prices for services performed.

Balance billing patients after their insurance pays is an issue nearly every state has addressed legislatively. Forty-nine states plus Washington, D.C., restrict providers from balance billing managed care enrollees who are part of an HMO, and 27 states restrict balance billing for PPO members. However, only 13 states make any provision for out-of-network providers, and most do so only in specific circumstances, i.e. emergency services, ambulance services, rural areas, etc.

Hospital-based practices, like anesthesiologists and emergency physicians, are particularly prone to patient complaints about out-of-network situations, especially when the hospital itself is in-network for the member. While this issue is not new, consumer driven-health plans with high copayments, deductibles, and out-of-pocket maximums make the balances after insurance payment higher than ever for patients.

As the issue gets more and more attention, what should physicians do?

  1. Make sure you are in-network with plans that you are contractually obligated to be in or plans that make sense for your practice. If your contract with the hospital or surgery center obligates you to maintain in-network status with certain payers, make sure you have done the necessary paperwork to make that happen. Also, participating with narrow networks that will send more patients to you or to large networks that will increase your overall bottom line also makes sense. Take time to regularly review your contract status as insurance companies come and go, or merge and dissolve.
  2. Annually review the contracts you do hold and negotiate rates that fairly compensate you. Regularly review your payer mix, the performance of other payers, and your case load to be certain your in-network contracts and the negotiated rates still make sense for your patients and your business.
  3. Have a policy in place for responding to patient requests for balance adjustments. Several consumer advocacy websites like Fair Health Consumer and NerdWallet Health are popping up to help patients deal with high, and sometimes unfair, medical bills. In a NerdWallet Health article called “A Guide to Negotiating Health Bills,” patients are encouraged to ask physicians for a discount and/or payment plans for out-of-network balance bills. A Fair Health Consumer article called “Out-of-Network Docs at In-Network Hospitals,” advises the same. Are you willing to accept those arrangements? If a patient has out-of-network insurance but can’t afford the high deductible, are you willing to grant a financial hardship discount? Work with your practice administrator, partners, and group members to establish a policy.
  4. Prepare your billing staff or billing company to handle these requests and to implement your policy. In most cases, you aren’t on the frontline to help patients understand the intricacies of our healthcare and health insurance systems. But your staff or billing company is. Make sure they understand your policies for dealing with out-of-network situations and have the tools they need for working with patients to resolve outstanding balances. If it is your policy to approve all bill adjustments yourself, respond promptly to requests from the staff or billing company.
  5. Ask the hospital, surgery center, and surgeons to help educate patients about the billing process during registration or when surgical procedures are being planned. By the time anesthesiologists meet with patients or emergency physicians arrive for their exam, insurance information has already been collected, health screenings or triage assessments are done, and the patient is prepped and ready for surgery or already having labs drawn. Learning that a member of their healthcare team is out-of-network at that point could be disruptive for patients. But approaching hospitals, surgery centers, and surgeons to help inform patients about out-of-network situations earlier in the process may help patients negotiate with insurance companies or even your billing office ahead of time to avoid unplanned write offs and headaches. Also, let hospital administrators know why you have maintained out-of-network status. Your reasons may open the door to future discussions or negotiations.
  6. Educate patients about their appeal rights for out-of-network denials or underpayment. Many patients feel helpless when their insurance network doesn’t pay for out-of-network services. Provide surgeons, hospital administrators, and your billing staff or billing company with the resources they need to educate patients about RAP clauses when no in-network providers are available and about their patients’ right to appeal for payment in those situations.

While the health care and health insurance climate is highly charged with controversy over worst-case scenarios, working toward win-win-win situations for patients, insurance companies, and your own practice helps everyone in the end.

— All rights reserved. For use or reprint in your blog, website, or publication, please contact us at cipromsmarketing@ciproms.com. Photo above by urban bohemian, via Flickr, used with permission under the Creative Commons License.


Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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