Tuesday, September 13, 2011

Out of Network Balance Billing

Out of network balance billing for P.A.R.E. claims are lurking and will pick your bank account clean. These hidden providers are like gunslingers in the wild west. They are not beholding to any rules and are free to charge whatever they want. If you don't pay they can ruin your credit and there is little you can do about it other than pay up.

Georgia State Representative Rusty Kidd found out the hard way when he took a tumble down a flight of stairs and had to be airlifted to Atlanta for treatment.

Kidd recovered. But he got another jolt when he opened a bill for the helicopter ride — about $27,000. Kidd’s insurer paid what it thought was reasonable: about $8,000. The company wanted Kidd to pay the rest.

“The average person can’t pay $19,000 and I can’t pay $19,000,” said Kidd, an independent.

People such as Kidd, who have what is considered full medical coverage, can end up with crushing medical bills on top of what they pay in deductibles and co-pays through a practice called “balance billing.”

It happens when patients get care from a hospital, doctor or ambulance company that is not part of the network of providers under contract with the patient’s insurer.

This is what insurers refer to as P.A.R.E. (Pathology, Anesthesiology, Radiology, Emergency) claims. While you MAY find par (network) providers in these situations the chances are these providers are not part of any network and are free to bill a "market" rate for their services.

Consumers who study their insurance benefit statements often marvel at the difference between the full-priced charges for a lab test or a hospital stay and the discounted rate negotiated by the insurer. The negotiated rate is often just a fraction of the full charge. Doctors and hospitals say their full charges reflect the expense of providing charity care and accepting government insurance plans that don’t cover their costs. But those footing the bill say that being asked to pay a charge that is often many times what an in-network or a Medicare patient pays simply isn’t reasonable.

How does the consumer know the amount charged isn't reasonable?

If two people buy an airplane ticket from Atlanta to New York, and one pays $99 while the other pays $450 for the same flight, which fare is "reasonable"?

Retail stores inflate their prices to cover such things as bank fee's charged for using debit and charge cards. Is it fair or reasonable for them to "overcharge" customers who pay cash?

Doctors say they also get squeezed by inadequate payments. What many insurers consider a “reasonable” payment is a sum many doctors say is too low. Some doctors are supporting a bill that would allow Medicare patients and their doctors to negotiate a rate — with the patient agreeing to pay what Medicare doesn’t cover.

Failing to pay what doctors consider a reasonable rate is hurting both the doctors and their patients, said Donald J. Palmisano Jr., executive director of the Medical Association of Georgia. “The patient doesn’t realize why they are paying more money and the physician is getting frustrated with the insurance company.”

There is no reason for the doctor to blame the insurance company. When a medical provider such as a doctor joins a PPO or HMO network they tacitly agree to the NEGOTIATED pricing for services rendered. In other words, by signing the contract they agree to accept the designated pricing as payment in full for services rendered.

Just as the non-par doc is free to bill a market rate, you are free to try and negotiate a lower fee directly with the provider. Since the provider is out of network, your health insurance company is unable to compel the provider to accept their payment as "in full". This is a private negotiation between you and the provider.

If you are unwilling to pay the amount as billed, and the provider is unwilling to discount their services, you are obligated to pay as billed. If you fail to do so the provider is free to turn your account over to collections.

This is not just limited to health insurance carriers. The same applies to docs that accept Medicare assignment.

If they don't like the payment schedule, they don't sign the contract.

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