Sometimes we work with or are seen by doctors who are not contracted with our insurance company. The decision to be non-contracted or non-participating is a freedom of choice decision that the provider makes. No one can force us to do anything, so an insurance company cannot force a doctor to become contracted with them. Sometimes the doctor may have been contracted but that contract was terminated. It could be because the insurance company wouldn’t pay the doctor’s claims; it could be that the payments made by the insurance company were less than the amount that the insurance company agreed to pay. It could be because the insurance company made many unreasonable refund demands. The number of reasons can be as many as stars in the sky, but, no matter why, the doctor terminated the contract and now the doctor is not contracted.
Some insurance companies have benefit plans that allows a patient to seek medical care from non-contracted, non-participating or out of network providers. There may be no requirement to obtain authorization to do this. There is a cost for doing so. The cost may be higher out of pocket expenses to be paid by the patient. This may be in the form of higher co-pays, or coinsurance. This may also be in the form of lesser claim payment amounts by the insurance company.
As an example, Mr. Steve goes to see Dr. X, who is contracted with Steve’s insurance company. The insurance company may pay $100 on a $120 claim. If Steve goes to see Dr. Y, his insurance company may pay $50 on a $120 claim. Mr. Steve has to pay the $70 balance due to Dr. Y as a result of going out of network. The secret to working with non-par providers is to know how much the insurance company is required to pay the non-par provider. Where is the answer to this secret? It’s in THE BENEFIT MANUAL.
Mr. Steve goes to his local emergency room for emergency care. The bill is $350. The claim is sent to Mr. Steve’s insurance company. The doctor who treated Mr. Steve is non-participating with his insurance. The claim is paid the amount of $13.68 with the explanation that the doctor is non-par and the discount is a cost savings to the member. The EOB also says per Florida Statute 641.3154, the doctor is prohibited from balance billing Steve. Basically what Steve’s insurance is saying is that the doctor must write off the difference between his $350 charge and the $13.68 payment. If the doctor doesn’t do anything, this could happen again and again; so now is show time!
Did the insurance company pay what they were supposed to pay? The doctor is entitled to be paid his fee of $350. Normally a patient pays any amounts that their insurance company didn’t pay. There have been class action lawsuits regarding this problem and the insurance companies have settled out of court. Now, we want to find our PROOF! We look in the benefit manual. The following is taken from an insurance company benefit manual regarding emergency care:
As you can clearly see, the emergency room care was supposed to be paid at 100% of the allowable charge. Look at the EOB to see what they allowed. For all we know, their allowed charge is $13.68 and by paying $13.68, they paid the claim correctly, so we don’t have an appeal. I personally like to create a spreadsheet on insurance companies that I bill. The spreadsheet will include the CPT codes that my doctor bills. It will contain my doctor’s charge for that CPT code. I add the allowed amount from the EOB for that CPT code. I may see a pattern where X Insurance allows $13.68 for CPT 99283 or 99203. I may see a different pattern, where X insurance paid $13.68, $75, $250 or $350 for 99203. This proof is what I use to show that Insurance X has no established allowed amount that they say they have.
I then use the highest allowed amount as my proof in my appeal. If they paid my claims at 100% of billed charges, then this is my evidence and my proof. I have the EOBs scanned. I can cleanse the EOB for other patients so I don’t violate HIPAA privacy laws.
I once walked into a meeting with an insurance company with 1,000 EOBs all showing payment at 100% of billed charges to fight the $13.68 payment and their stand that $13.68 is all they pay for 99203. They wanted to stand behind their $13.68 but their smug smiles disappeared when asked, how much they paid on this claim? 100%. How much on this claim? 100%. This went on, and on, and on. After so many EOBs, showing 100% payment, the look of defeat became visible on their faces simply because my Kung Fu was stronger than theirs.
I also provided additional proof, from their own BENEFIT MANUAL; that 100% was what they were supposed to pay. After we received our check for the balance we were due, their $13.68 payment became history. With strong proof; I don’t care if the amount owed is $1. It’s the principal that matters. If my doctor treats 25,000 patients per year and this is $1 per patient that adds up to $25,000 that I’m fighting to win. If the Doctor was supposed to be paid at 100% and he wasn’t paid $249 of the bill, that’s $6,225,000 that has been lost. It is worth it to go after such an amount of money. That can pay my salary for more than 20 years with some very nice Christmas bonuses!