# In Network / Out of Network Rules Texas?



## gr8gal61 (May 20, 2013)

I have a question that needs clarification. I've been disagreeing with the processing of claims since coming on board but would like to find the "rule" for Texas if anyone has any experience. 
I have one facility that is IN network and one that is OUT of network. Patients are not being informed of the "out of network" facility when they are having surgery performed at the out of network facility, resulting in either no out of network benefits, or a patient having an OUT of network claim processed OR the patients' surgical benefits deductible not crossing over and the patient is then faced with having to satisfy another deductible IN network. *My question *is: the doctor is under the assumption that he can "match" their IN network benefits and simply write off the patients' balance after sending the patient 3 statements. I disagree because of several reasons. The patients' benefits are simply being verified through an automated program, Allscripts which is NOT up to date and in deductible is not listed as a cross over or not until someone physically calls customer service and asks that particular question. I've never heard of the 3 times a statement rule but know that if you write off a balance...the patient should have a financial hardship filed and or the same rates must be passed on to ALL patients, whether In network or self pay. 

Please help as I am attempting to prove that this type of balance billing could easily be considered dual fee schedules that is not offered to all. 

Thanks so much for any information where someone has first hand experience. 

Also.....the provider is IN network if procedures are done at one of his facilities ! Could this affect his contract with the insurance companies?


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## mitchellde (May 20, 2013)

The patient must be informed that the facility you have scheduled the procedure to be performed in is out of network.  The 3 times rule is being really stretched here.  That is a ruling that states you must send a patient 3 legitimate bills before decising what may be done with the balance, but you must have a written office procure for this and all patients are treated the same, you cannot chose to write of only certain ones.  And you cannot decide ahead of time that you have no intention of collecting that you are sending the bills as a formality.


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## gr8gal61 (May 20, 2013)

Debra, thank you. I knew I was correct, just needed some back up as proof!


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