Wiki UMR Processing as In Network when Out of Network MD

[orthobiller2017]

I work for an out of network surgeon. He has been out of network for almost a decade. Recently one of our surgical claims for UMR was processed as in network. The surgery had been pre-authorized and it was an elective surgery so not a surprise bill. Initially I thought there was an error on UMR's side. However they are standing firm that it was priced as in network because facility is in network- no further compensation is due and there is 0 patient responsibility despite claim being paid at 1/2 billed rate. I have called and sent letters to no avail. I haven't even received correspondence back addressing my appeal. I tried NYS Insurance Commission but it doesn't handle ERISA policies.
I imagine there must be some external review available given that UMR hasn't even addressed the original appeal letter. Any advice would be greatly appreciated.
Of note the same patient's Office Visit was processed as out of network and other UMR patients (different employer) were processed as oon during this time frame

 

[JenniferB7]

There are a few things you can do:

1. You can contact the provider relations department for explanation. Sometimes they can correct this kind of an issue. I would verify with Provider Relations to confirm that a contract does not exist and if not, then you are not contractually (legally) obligated to accept the write off on the EOB. If Provider Relations states you are required to accept the write-off, then require them to provide proof that you are legally obligated to do so. The patient's benefit plan is a contract between the patient and the insurance plan, not the provider.

2. You can file a complaint with the US Department of Labor, who has oversight of ERISA plans. (https://www.dol.gov/agencies/ebsa/about-ebsa/ask-a-question/ask-ebsa)

3. Worst case, you may need to contact an attorney.

Hope that helps!