Wiki Out of Network ER Physicians

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mbarbour

Networker
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Raleigh, NC
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Can an Emergency Room doctor not contracted with the hospital balance bill for professional charges four out of network insurances?
 
For commercial insurance you can balance bill if a non-par ER provider. You would still want to keep up with what the adjustment reason was especially with all the silent PPO networks out there. Although being non-par isn't to be used as a blank checkbook. Still need to follow proper CPT coding guidelines.
 
Thanks so much for reply! I wanted another opinion, an insurance company kept telling us that we could not balance bill. You know you know something, but just want that extra opinion. I appreciate it. :D
 
We try to persuade you not to but in the end there is nothing we can do to prevent it. Now on the other hand if its being priced off a "rental network" you will have to dig deeper. if its Usual and Customary rate then no they can't legally stop you. I believe the network used should be on the EOB in the case of rental networks. If not you can always check with the payer.
 
Check your State Laws

In the State of California there are statutory restrictions on balance billing for emergency services provided by out of network providers. It would be a good idea to verify if the state you are billing in has similar prohibitions in place.

Although even if they don't that won't stop the insurance companies from trying to claim that balance billing cannot happen in order to try to keep reimbursement at U&C rates...
 
The problem of have with this is, if the facility is in network and the patient presented to the ER, how are they suppose to know that the physician that treated them was in fact out of network when the facility is listed as in their network?? I think this is not fair to the patient to balance bill them when they had every reason to believe that they were following in network rules.
 
CLCameron said:
In the State of California there are statutory restrictions on balance billing for emergency services provided by out of network providers. It would be a good idea to verify if the state you are billing in has similar prohibitions in place.

Although even if they don't that won't stop the insurance companies from trying to claim that balance billing cannot happen in order to try to keep reimbursement at U&C rates...
Click to expand...

I did not know this. Time to lobby for this in MA :D
 
mitchellde said:
The problem of have with this is, if the facility is in network and the patient presented to the ER, how are they suppose to know that the physician that treated them was in fact out of network when the facility is listed as in their network?? I think this is not fair to the patient to balance bill them when they had every reason to believe that they were following in network rules.
Click to expand...

One of the many reasons this is a hot button topic in states where there is no prohibition in place.
 
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