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if we see a patient in the hospital and we are out of network with there insurance dont we still get paid ??? also this patient does not have any out of network benefits
 
Some do for out of network. Is your claim being denied? Typically on an HMO if the service is performed by out of network provider especially when patient doesn't have a choice who they see (Inpatinet/Obs/ER for example) the payer will still reimburse. Some make it a step harder for to get you to contract by paying the patient instead of the provider to make it harder for you to collect in hopes you will contract. for direct payments.
 
yes the claim was denied for being oon and the pt has no oon benefits the dr saw the patient in the hospital
we dont know what ins they have when they see them in the hospital we are not the ones getting the information the hospital is
 
We are OON internists and our Doctors round at the hospital.
Yes certain insurances pay the patient directly, Blue Cross Blue Shield and United Healthcare are the two major ones we encounter.
But this is only if the patient has out of network benefits.

We had one case were the patient after receiving our bill called their insurance and were told that if they were admitted through the ER then they would pay regardless. This was not the case and appealing didn't do any good because the patient didn't have OON network benefits period!

I don't know about all states but NY now has the "Surprise Act" that basically states a physician can not bill the patient directly if they do not accept their insurance and the patient was not given the choice ( this is only in a hospital setting)

Bottom line if you see the patient and they didn't request you or give you something in writing saying they will pay if their insurance doesn't ( that never happens) then you don't have a leg to stand on. ( at least here in NY)


http://www.mssny.org/MSSNY/Governme...PRISE_BILL_RULES_GO_INTO_EFFECT_MARCH_31.aspx
 
I have had this issue before and it depends on the insurance company. For example: for some UHC plans we are out of network and when the patient is seen in the hospital and our providers do surgery we bill our claim without an authorization. If it comes back denied we call and let UHC know that the patient was in the hospital and had surgery. The hospital usually gets an authorization and the procedure is covered under their authorization. I have had a few procedures that were not covered and had to file an appeal. I don't know of an easier way to handle this, we deal with it often and with other insurances beside UHC.
 
I know this is an old thread that I stumbled upon, but I deal with this a bit. I work for an ASC, out of network with Anthem BCBS, and I would estimate that 2/3 to 3/4 of the time, the payments go to the patient. What makes it more complicated is that most of the time BCBS won't tell us the check# of the payment sent to the patient, or if/when the check was cashed. No one in my office ever thought to keep track of this, or put limits on services until I started keeping track of it, on my own initiative, several years ago. Some patients received tens of thousands of dollars, and we continued to see them, because no one was paying attention. It really is double work: first, trying to get BCBS to pay, then trying to collect from the patient. My advice: keep track of it, and be very strict about No Money/No Services.


John Methgen, BS, CPC-A,CPB
 
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