orthobiller2017
Networker
I have a complex question
I work for an oon MD. Over the years OON reimbursement has changed dramatically. Not only are deductibles and coinsurance higher but most plans now utilize different fee schedules to determine OON allowance. For instance you can have Patient A with Cigna that uses Fair Health 80% and Patient B with Cigna that uses Medicare rate X 140%.
Now because the # of patients like Patient B have rapidly increased with plans like Oxford, Cigna, UHC etc all having Medicare Rate based plans our practice has been steadily loosing patients because people cant afford to pay the balance billing.
So we are trying to brainstorm ways to keep patients but also be compliant. We also have angry patients who had surgery with us years before and now insurance is different and responsibility is much higher as new plan is MNRP.
Going in network is not a consideration at this point because there are still some OON plans that utilize Fair Health schedules
I have been told by legal that as long as an insurance doesn't base their allowance on our billed charge (ie a % of our billed amount) we are not obligated to charge them above the insurance allowance. We would ofcourse be charging them the deductible/coinsurance based on the insurance but do not necessarily have to bill past the insurance allowed.
Now if we do this as a rule (meaning regardless of whether its an MNRP plan or RNC plan) and provide notice to insurance company (like in box 19 of claims) would this be ok or would this be a compliance issue.
I work for an oon MD. Over the years OON reimbursement has changed dramatically. Not only are deductibles and coinsurance higher but most plans now utilize different fee schedules to determine OON allowance. For instance you can have Patient A with Cigna that uses Fair Health 80% and Patient B with Cigna that uses Medicare rate X 140%.
Now because the # of patients like Patient B have rapidly increased with plans like Oxford, Cigna, UHC etc all having Medicare Rate based plans our practice has been steadily loosing patients because people cant afford to pay the balance billing.
So we are trying to brainstorm ways to keep patients but also be compliant. We also have angry patients who had surgery with us years before and now insurance is different and responsibility is much higher as new plan is MNRP.
Going in network is not a consideration at this point because there are still some OON plans that utilize Fair Health schedules
I have been told by legal that as long as an insurance doesn't base their allowance on our billed charge (ie a % of our billed amount) we are not obligated to charge them above the insurance allowance. We would ofcourse be charging them the deductible/coinsurance based on the insurance but do not necessarily have to bill past the insurance allowed.
Now if we do this as a rule (meaning regardless of whether its an MNRP plan or RNC plan) and provide notice to insurance company (like in box 19 of claims) would this be ok or would this be a compliance issue.