Patient Advocacy: Healthcare on your
side
a weekly blog by Martine Brousse,
Healthcare Specialist, Patient Advocate, Certified Mediator
AdvimedPro
Reduce
your Out Of Network Bills *
Scenario: You recently had surgery, or ended up in the
ER. One (or more) physician evaluated you. Not all are part of your insurance
network, and you are now receiving outrageous fees. You did not choose
them or directly request their services. How can you get out of paying
these bills?
This is routinely happening in our times of restricted
insurance coverage, smaller networks, reduced choice
of in-network providers and growing trend among physicians of opting
out of all contracts.
Appeals made by patients are often rejected. Reasons
range from "it is the patient's responsibility to use in network
providers" to "the policy has a strict exclusion for all out of
network services".
Understand that you may have to pay something for the
services rendered to you. But know that you do have options, and rights, at
your disposal before taking out your credit card.
1. Get the insurance to pay
If the hospital is "in network", but the
insurance paid a provider at the out of network rate, file an appeal and demand
they pay the higher contracted rate based on the preferred contracted status
of the facility. Other arguments should include: You had no choice in the
matter, you went to the correct facility, services were medically necessary,
this was the only specialist available, or none of the specialists on call were
providers (often the case with anesthesiologists).
Ask that the insurance attempt to sign a one-time
agreement with the physician. Inform the office: such deals are routinely (and
gratefully) accepted.
2. Invoke your rights
Your patient's rights include the rights to receive
timely, appropriate, adequate, qualified care. If the in-network or preferred
provider could not render the service soon enough, lacked the necessary
qualifications, expertise or training, was too far away from your location, or
if you could not trust him for specific reasons, your insurer must cover the out-of-network
cost of the provider you chose.
If a service was rendered under emergency conditions,
specific policy guidelines and regulations kick in. Public Health
Service Act (PHS Act) section 2719A and the ACA ("Obamacare") impose on health insurances to fully
cover emergency services in an emergency department of a hospital without
regard if the provider is out of network, and requires insurers to apply
the same financial liability to the patient as would have been if in
network.
3. Call your State's Insurance Commissioner
If your appeal is still denied despite using these
arguments, consult your State's Insurance Commissioner's website for information
on how to submit a grievance against the health plan. Include a copy of all
relevant documents when filing. Some states offer free phone consultations to
determine whether you have a case.
4. Deal with the provider directly
A provider may refuse an insurance agreement or to
write off your balance after an "in network" payment. Request to meet
the office manager to negotiate. Meanwhile, send small monthly payments to
avoid collection action.
Your insurance representative may be able to help you
determine an acceptable settlement, as would a billing advocate. Remember that
a one-time "paid in full" remittance is more attractive than monthly
payments.
5. Ask the referring physician
If all fails, contact your surgeon, explain the
situation and ask for assistance. A non-contracted provider, counting on more
referrals and work from his colleagues, may have to learn to be more flexible
and less greedy. Another physician is the best placed to explain this delicate
situation.
The referring physician, or his office manager, may be
able to use his contacts with the facility's officers to get a bill reduced or an
application for financial assistance pushed through.
If the provider belongs to a medical group, as
anesthesiologists and ER physicians often do, file a request for a review of
your case and ask for a fee reduction directly with the managing director. They
often are more sensitive to negative comments and potential backlash,
especially if you indicate a copy is being forwarded to the referring physician
and to the administrator of the facility.
In conclusion:
A negative response to an insurance appeal or the initial
refusal of a reduced fee should not deter patients from seeking other avenues
to get a better outcome. Patient satisfaction and the threat of public exposure
are growing factors forcing medical providers to "play nice". Knowing your rights and demanding they are
respected are powerful incentives, as are hiring a patient advocate or going up
the corporate ladder.
* A seen on NerdWallet
* A seen on NerdWallet
© [2016] Advimedpro.
© [2016] Martine G. Brousse.
All rights reserved.
My
objective is to offer you, the patient, concrete and beneficial
information, useful tips, proven and efficient tools as well as
trustworthy supportive advice as you deal with a system in the midst of sweeping adjustments, widespread misunderstandings and complex requirements.
AdvimedPro (424) 999 4705 or (877) 658 9446 fax (424) 226 1330
