Navigating Out-Of-Network Claims: Tips For A Hassle-Free Experience

Navigating Out-Of-Network Claims

Unlike in-network care, out-of-network providers do not have contracts with specific health plans that require them to accept a negotiated reimbursement rate. This means that they can balance bill patients for services rendered. Whether due to an emergency or the fact that your doctor is not in-network, there will be times when you need to use out-of-network healthcare providers. Fortunately, there are steps you can take to mitigate the potential of unexpected medical bills.

Educate Yourself

The first step to navigating out-of-network claims is to educate yourself about your insurance. Understand what out-of-network costs are, as well as your insurance policy’s coverage and reimbursement rates. In most cases, it is best to find an in-network provider when possible, but there may be situations where this is not feasible (e.g., if you are traveling or need specialized care). Additionally, understand how your insurance company processes claims for out of network insurance providers and any additional fees that can be charged by the healthcare provider, such as a facility fee. These fees are not typically included in your negotiated rate, and if they aren’t, you may be responsible for the entire balance of your bill. If you need to see out-of-network specialists for ongoing care, requesting a network gap exception from your health insurance company is a good idea. You must provide a letter from your in-network primary care physician outlining why the treatment is necessary and how it would save your health insurance company money. Additionally, remember that you can enlist your healthcare provider’s help to call your insurance company on your behalf and make the case for why an out-of-network claim should be paid at in-network rates.

Make The Most Of Your Deductible

To be in-network with your health plan, medical providers must sign a contract agreeing to reimburse the insurer at a predetermined, negotiated rate. These rates are often established and published by the Centers for Medicare and Medicaid Services, and they serve as a benchmark that benefits plans use when negotiating fees with medical providers. Health insurance companies typically only fight back against out-of-network bills when they feel the provider’s billing practices are egregious or the patient was mistreated. Even then, it’s often the case that an insurance company needs to have leverage with an out-of-network physician and will be unable to negotiate a reduced rate. This is a big reason why it’s so important to ask about out-of-network charges upfront and to review your policy or contact your insurer to see what percentage of the fee counts toward your deductible. Doing this can prevent surprises regarding medical costs and better plan for your future healthcare needs. Although the monthly costs or premiums associated with a health insurance plan are typically clearly spelled out, information about a plan’s deductible takes more work. But understanding the deductible and how it affects your healthcare costs is well worth the time investment.

Keep An Open Line Of Communication

Health insurance plans each have their network directory, and patients must know whether or not a healthcare provider is in-network with their specific plan before making an appointment. Suppose a healthcare provider isn’t listed in the directory for a particular insurance company. In that case, the provider does not have a direct contract with the insurer and will be considered out-of-network. If you have a specific healthcare need and no in-network providers are available in your area, you can ask for an out-of-network exception. Many insurance companies will grant these network gaps when a patient has no other options. Out-of-network reimbursement rates are based on what Medicare pays for a particular procedure in the zip code where services are performed. It can take hours of research to determine precisely how much one would be reimbursed for out-of-network care. Still, patients must keep an open line of communication with their insurance provider to ensure they receive fair reimbursement for out-of-network claims. There are times when going out-of-network is a necessity, and patients must do all they can to keep costs down when it does happen. With a bit of research and an open line of communication, there’s no reason why out-of-network claims should be any more expensive than in-network ones.

Stay Persistent

In health insurance, only some topics are as complex or fraught with financial peril as out-of-network claims. Out-of-network providers don’t have a contract with your insurance payer and tend to charge higher rates than in-network providers. As a result, your insurer may pay only a tiny percentage of the cost of out-of-network services, and you could end up footing the bill for the rest. Fortunately, you can combat these high costs by being aware, understanding, and proactive. Be sure to verify a provider’s network status before making an appointment, even if your doctor recommends a specialist. Keep in mind, however, that there are situations where it might be unavoidable to go out of network, such as if you need specialized care available only from a particular specialist or facility. When that happens, be prepared to fight. Be persistent with your insurer, and keep refiling your claims until you get the total amount they owe you. To help you do that, SuperBill has a team of hands-on specialists who handle your medical bills and appeals around the clock.

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