Billing as an out-of-network provider poses unique challenges and obstacles to getting the reimbursement you deserve. Don’t let insurance companies give you the run-around just because you’re not “in-network.”
You can take specific steps to successfully bill for out-of-network care, according to medical billing expert Stephanie Thomas in her webinar, “How to Get Paid for Out-of-Network Care in 2018.” These steps involve, among other things, verifying benefits and medical necessity, complying with contract verbiage guidelines, getting patients to pay their portion, and appealing for major payers.
Here are a few tips to get you started on more successful out-of-network billing:
Help Your Patients Understand Their Benefits
When your patient’s health insurance plan changes or when a patient switches health insurance providers, make sure he checks on and understands any changes to his benefits, according to a Get Better, Inc.. Switching plans can cause a patient to lose out-of-network benefits altogether.
Pitfalls: Plan and out-of-network benefit changes can lead to unpaid claims for your practice and increased out-of-pocket costs for your patients, stated The Patriot Group in a blog post. Insurance companies may intentionally confuse patients and providers alike with dense, hard-to-understand contracts. These companies know that you will be “stuck between choosing to write off otherwise collectible debt or fight a long and expensive battle to appeal when they deny even legitimate claims,” the firm, which specializes in healthcare compliance and litigation, noted.
Benefits: If your patients have a better grasp on what services and how much their plan covers for out-of-network services, you’re more likely to receive payment for their portion of the bill. Patients who have a clear understanding of their coverage before receiving services won’t be surprised later on by their medical bills.
Keep an Eye on Your Claims Payments
Insurers may deny or delay your claim reimbursement due to incomplete or missing claims, The Patriot Group stated. To hold insurance companies accountable for paying your claims, make sure you have a copy of the claim, proof of submission, and a receipt of the claim. Also, make sure you’re submitting clean and complete claims in the first place.
Careful: Additionally, don’t ignore notices from insurers requesting specific paperwork, such as a W9. More and more insurers are requiring out-of-network providers to verify their practice information before the company will pay the patient’s claims, Get Better warned. Keep in mind that completing this paperwork doesn’t mean you’re creating a contractual relationship with the insurer or agreeing to be in-network – you must complete this paperwork for the insurer to list you as an out-of-network provider so it can pay your claims.
Another tip: In some cases, you may be able to use protections under the Employee Retirement Income Security Act (ERISA) to get insurers to remit your claims payments, according to The Patriot Group. ERISA applies to health plans that are employer-sponsored, but exempts plans that cover municipal, government, or state workers and religious entities. Under ERISA, insurers have many responsibilities and obligations to provide quick and accurate claims reimbursement.
Watch for Emerging Legislation
In 2017, most states didn’t have laws that directly protected consumers from “balance billing” by an out-of-network provider, according to a study by The Commonwealth Fund. And of the states that do offer protections, only a handful have a comprehensive approach to safeguarding consumers and gaps remain.
Look ahead: But more and more states are passing balance-billing legislation, with recent bills up for consideration in Texas, New Jersey, and Georgia, as well as three federal actions that may address unfair “surprise” medical bills for out-of-network care. Stay current on pending legislation in your state because it will certainly impact your billing practices.
Takeaway: To ensure that you’re paid appropriately for out-of-network care, make sure you understand the financial agreements and authorizations, patient cost-sharing, and contract negotiations, Thomas stresses. Know how to verify out-of-network benefits properly and get a solid understanding of the differences in payment between in-network and out-of-network.
