Wiki Out of Network Facility Reimbursement

[PJZ ASC Coder]

I code and bill for an out of network ASC and recently BCBS of Texas plans have been allowing at a rate lower than the Medicare Fee schedule for ASC. In the past they have allowed per the Medicare Fee schedule or slightly higher. Has this been an issue for anyone else? Can they allow at such a low rate? Any input would be greatly appreciated.

 

[thomas7331]

I think that by definition, if you are 'out of network' then that means there is no contract between your facility and the plan, so there is no mutual obligation either on the part of the payer to allow a particular amount, or on your facility's part to accept an amount as payment in full. Payers will of course not want to pay much to out of network facilities because that defeats the purpose of having a network - they need to give their patients an incentive to go to their own providers.

So I think the short answer to your question is that yes, they can do that. Your only protection is to try to get an authorization or negotiated rate in place before the services are rendered, or to collect from the patient in advance if there is expectation that the insurance will not pay in full.

The only exception I can think of to this is if the patients are enrolled in a managed Medicare or other government plan - in that case, the payers and providers are required to follow the government regulations even if there is no network contract in place.