Navigating Out-Of-Network Insurance Billing: A Comprehensive Guide

Out-of-network billing, also known as surprise medical bills, occurs when a patient receives a bill for the difference between the out-of-network provider's fee and the amount covered by their health insurance. This can happen when patients assume that facility-based providers, such as radiologists and emergency physicians, are in-network because their surgeon and hospital are. To avoid surprises, it's important to educate yourself about your insurance plan's benefits and limitations. You can do this by reading and understanding the plan's language, asking your insurance provider or HR manager questions, and using resources that provide cost calculators for common procedures. If you are billed for an amount that is much higher than expected, you may be able to dispute the charges. As an out-of-network provider, you have two options for billing: provide the client with a superbill and have them file a claim for reimbursement, or submit an out-of-network claim on the client's behalf.

Understand what a 'surprise medical bill' is

Surprise medical bills, or out-of-network bills, occur when a patient receives a bill for the difference between the out-of-network provider's fee and the amount covered by the patient's health insurance, after co-pays and deductibles. This is known as "balance billing".

Surprise medical bills can happen when patients receive care outside of their health plan's network without realising it. For example, a patient might choose a surgeon in their plan's network, but they may not be asked about the anesthesiologist. Patients often assume that facility-based providers, such as radiologists, pathologists, and emergency physicians, are in-network because their surgeon and hospital are in-network.

Surprise medical bills are also common when patients have no ability to choose their doctors, such as in an emergency or when getting prepped for surgery. In these situations, patients often receive treatment from a doctor or hospital that turns out to be out-of-network.

The No Surprises Act, which came into effect on January 1, 2022, protects people from unexpected out-of-network medical bills for emergency room visits and non-emergency care related to a visit to an in-network hospital. The Act also establishes an independent dispute resolution process for payment disputes between plans and providers.

State and federal laws also protect patients from surprise medical bills. For example, state law bans surprise bills from ground ambulance services if the patient has a state-regulated plan. Additionally, some health insurance coverage programs, such as Medicare and Medicaid, already have protections against surprise medical bills.

Learn about the No Surprises Act

The No Surprises Act (NSA) is a federal law that came into effect on January 1, 2022, to protect people from surprise or unexpected medical bills. It applies to most types of health insurance and covers emergency room visits, non-emergency care related to a visit to an in-network facility, and air ambulance services.

The NSA provides protection from surprise medical bills in the following scenarios:

• Emergency services (including post-stabilization services rendered after an emergency medical service)
• Non-emergency care services provided by out-of-network providers at in-network facilities

Under the NSA, patients are protected from "balance billing", which occurs when a patient receives a bill for the difference between the out-of-network provider's fee and the amount covered by the patient's health insurance, after co-pays and deductibles. The Act ensures that patients are only liable for their regular in-network cost-sharing amounts and deductibles. It also requires providers and health plans to help patients access accurate healthcare cost information.

The NSA establishes an independent dispute resolution (IDR) process for payment disputes between plans and providers, and provides new dispute resolution opportunities for uninsured and self-pay individuals. This process is based on an arbitration model, where an arbitrator chooses between the final payment offers submitted by each party. The NSA also requires providers to give good faith estimates of medical costs to uninsured or self-paying individuals.

The NSA is enforced by various federal agencies, including the Department of Health and Human Services (HHS), the Department of Labor, the Department of Treasury, and the Office of Personnel Management (OPM). States also have a role in enforcement, particularly for state-regulated plans.

The NSA is intended to improve transparency in the healthcare system by requiring insurers and providers to maintain up-to-date provider directories, disclose in-network and out-of-network deductibles and out-of-pocket limits, and provide patients with good-faith cost estimates in advance of medical services.

Know your plan's benefits and limitations

Knowing your insurance plan's benefits and limitations is crucial to avoiding unexpected costs and making informed healthcare decisions. Here are some detailed instructions to help you understand your plan's benefits and limitations:

Firstly, familiarize yourself with the different types of health insurance plans available. The four main categories are Bronze, Silver, Gold, and Platinum. These categories indicate how costs are shared between you and your insurance plan. Additionally, different plan types, such as HMO, PPO, and POS, have varying levels of coverage for out-of-network care. Understanding these options will help you choose the plan that best suits your needs.

Next, review your Summary of Benefits and Coverage (SBC). The Affordable Care Act (ACA) requires all insurance companies to provide this document, which outlines your benefits and coverage limits in clear and understandable language. The SBC will detail what services are covered and to what extent. It is important to remember that even plans from the same company can vary in their coverage, so be sure to review your specific plan's SBC.

Additionally, understand the essential health benefits that all Marketplace plans are required to cover. These include outpatient care, hospitalization, pregnancy and maternity care, mental health services, rehabilitative services, preventive and wellness services, and pediatric services. While these benefits are mandated, specific services covered within each category may vary by state, so be sure to check your state's requirements.

Furthermore, be aware of the limitations of your insurance plan. While there are no longer lifetime or yearly dollar limits on essential health benefits, plans can impose limits on non-essential health services. Additionally, some plans may have higher deductibles for out-of-network services, so understanding these limitations will help you anticipate potential costs.

Lastly, take advantage of the resources available to you. Utilize your plan's cost estimation tools, doctor search tools, and drug formularies to make informed decisions about your healthcare. Don't hesitate to contact your insurance company's Member Services team to clarify any questions or concerns you may have about your coverage. They are there to help you navigate your plan's benefits and limitations.

Remember, by actively educating yourself on your plan's benefits and limitations, you can maximize your insurance coverage and make more informed healthcare choices.

Determine if the same service is available within your network

When determining if the same service is available within your insurance network, it is essential to understand the concept of "in-network" and "out-of-network" providers. An in-network provider refers to a doctor, medical facility, or healthcare provider that has contracted with a particular insurance company to provide services to its members at agreed-upon rates. Out-of-network providers, on the other hand, have not agreed to accept predetermined payment amounts and may charge higher prices.

To verify if a specific service is available within your network, there are several steps you can take:

• Contact Your Insurance Company: Reach out to your insurance company's customer service or member services team. They can provide up-to-date information about your plan's network of providers. Have your insurance plan details and the specific service you require handy when making the call.
• Utilize Online Resources: Most insurance companies offer online tools to help you find in-network providers. Visit your insurance company's website and look for a "Find a Doctor" or "Provider Search" function. You can search by name, specialty, or location to determine if the service you need is available within your network.
• Check the Provider's Website: If you already have a specific provider in mind, check their website to see if they list the insurance plans they accept. However, keep in mind that this information may not always be up-to-date, so it's always a good idea to confirm with both the provider and your insurance company.
• Ask Your Provider: When you visit your healthcare provider, ask them if they accept your insurance plan. Show them your insurance card, and they may be able to tell you if they are in-network. However, it's still advisable to confirm with your insurance plan to avoid unexpected costs.
• Regularly Check Provider Networks: Insurance companies frequently review and update their networks, so it's important to verify that your provider remains in your network before scheduling appointments or switching plans.

By following these steps, you can determine if the same service is available within your insurance network, helping you make informed decisions about your healthcare choices and potentially saving you from unexpected out-of-pocket expenses.

Ask your insurance provider questions

When it comes to billing insurance out of network, there are a few key things to keep in mind. Firstly, it's important to understand that out-of-network billing, or "surprise medical bills," occur when a patient receives a bill for the difference between the out-of-network provider's fee and the amount covered by their health insurance, after co-pays and deductibles. This can happen when patients assume that facility-based providers, such as radiologists or emergency physicians, are in-network because their surgeon and hospital are. To avoid surprises and make informed decisions, it's crucial to educate yourself about your insurance plan's limitations and options. Here are some questions to ask your insurance provider:

• Ask about your plan's benefits and limitations: By understanding what your plan covers and what it doesn't, you can make more informed decisions about your healthcare. Inquire about deductibles, co-pays, and out-of-pocket maximums.
• Inquire about out-of-network costs: Find out if your insurance plan provides any coverage for out-of-network services and what the process is for reimbursement. Ask about any additional paperwork or requirements needed for reimbursement claims.
• Discuss alternative options: If you regularly see a specific provider who is out-of-network, ask your insurance provider if there are any alternative plans during the open enrollment period that would include this provider in your network.
• Understand the dispute process: Inquire about the steps you should take if you disagree with a billing charge or feel that your rights under the No Surprises Act have been violated. Understand the review and appeal process for denied claims.
• Seek clarification on specific providers: If you have a particular provider in mind, ask if they are considered in-network or out-of-network. This information can help you plan your healthcare choices more effectively.
• Inquire about assistance programs: Ask if there are any assistance programs or financial resources available to help offset out-of-network costs. Many treating hospitals, facilities, or providers have programs to assist with financial burdens.

Remember, the more informed you are about your insurance plan and its specifics, the better equipped you will be to navigate out-of-network billing and make cost-effective healthcare decisions. Don't hesitate to reach out to your insurance provider's customer support or your company's Human Resources department for clarification on any of these questions.

Frequently asked questions