Getting Paid When the Provider is Out-of-Network: How Much, How Soon, What Hassles?

The theme for the latest round of private insurance payment disputes seems to be payment hassles that physicians and other health care providers experience when dealing with private insurers, particularly managed care companies. Here are a few cross references to issues that I hope to cover in greater detail within the next day or so:

1) Disputes over the calculation of the Usual, Customary and Reasonable payment for a physician who has not signed a contract with a Payor, as demonstrated by Cuomo’s lawsuit over alleged underestimation by United Healthcare’s wholly owned subsidiary Ingenix. The allegations also discuss a conflict of interest between United HealthCare’s representations to its Members and its relationship with Ingenix.

Link to Cuomo Notice of Intent to Sue

Link to NY Attorney General’s Office Press Release 

2) Disputes over the calculation of the Usual, Customary and Reasonable payment for a non participating physician who was not chosen by the patient, specifically hospital based physicians and physicians providing emergency services, as demonstrated by the AMA’s dispute with Aetna. The AMA is claiming that Aetna’s method of paying out-of-network physicians at 125% of Medicare violates its 2003 settlement agreement in the HMO Class Action. They also claim that Aetna has a duty to disclose to patients on their explanation of benefits that the physician is entitled to bill them for the difference between the 125% and the physician’s charge. The AMA alleges that Aetna is telling patients that they have no responsibility to pay the balance to these “involuntarily chosen out-of-network” physicians.

Link to AMA News

Link to Hartford Courant Article 

3) Disputes over the payment process used by Payors when the provider is out-of-network and counter-disputes by Payors that out-of-network providers are delaying the transfer of patients back to Participating hospitals, as demonstrated by the dispute between the Prime Hospitals in California and Kaiser Permanente.

Link to San Diego Union Article 

Comments

[Tessiebm]

Good post., brother

[Tracey Dodson]

So how do providers get reimbursed when the patient chooses to go to an out-of-network physician because that physician is the only specialist in a 50-mile radius! How can a provider determine the patient's out-of-pocket costs when the insurance companies will not disclose their 'Maximum Allowable' schedule?? Example: Breast Reconstruction patient - billed insurance $30,000 and they paid $2,000 -- on the EOB it states that the patient is responsible for $27,000!!! The physician is willing to give a discount to the patient but come on! The insurance company came out way better don't you think??