Tag: Out Of Network

NEW RULES:Bans on balance billing and out-of-network cost-sharing

Effective Jan. 1, 2022, Health Plan commercial members will be protected from balance billing after receiving emergency care and nonemergency care from certain out-of-network providers at in-network facilities. The No Surprises Act, which is included within the Consolidated Appropriations Act of 2021 (the CAA), provides the following:

Effective Jan. 1, 2022, Health Plan commercial members will be protected from balance billing after receiving emergency care and nonemergency care from certain out-of-network providers at in-network facilities. The No Surprises Act, which is included within the Consolidated Appropriations Act of 2021 (the CAA), provides the following:

Bans surprise billing for emergency services

If a member receives emergency services, they will be covered at the in-network rate, and the services do not require prior authorization from Health Plan. This is true even if the services are received at a facility or from a provider that does not participate in their network. Additionally, members will be protected from balance billing when receiving post-stabilization services at a nonparticipating facility.

Bans balance billing and out-of-network cost-sharing for emergency services as well as certain nonemergency services performed by a nonparticipating provider (or facility on behalf of the provider) at participating health care facilities including out-of-network ancillary providers such as pathologists, anesthesiologists, and radiologists at in-network facilities: 

In these situations, the member’s cost share cannot be higher than the cost share would have been if the services were provided by an in-network provider or an in-network facility. The member’s cost share must be based on the in-network rates.

Bans balance billing for out-of-network air ambulance service

I’m out-of-network with the payer requesting an audit. What right does the company have to audit my records?

A LOOK INTO (MANAGED) BEHAVIORAL HEALTHCARE: AUDITS

A trending issue has popped up in my inbox and I thought I’d take a quick minute to post this crude blog article: Out of Network Behavioral Health Providers receiving Audit Requests from Non-Contracted Health Plans.

More and more audits seem to involve payers looking at psychologists who are out-of-network providers. Such psychologists may ask what gives the company the right to audit when they have no provider contract with the company. (Provider contracts typically require that you comply with the company’s audit requests.)

The answer is that while you may not have audit obligations to the payer in this situation, the patient’s contract with the company may require the patient to allow that his or her care and records be audited in order for the patient to be reimbursed or to have further care authorized. The payer might also claim that it has the right to determine if your out-of-network services met the medical necessity definition in the patient’s insurance plan. Generally, the patient’s best interest is served by complying with audit requests that are reasonably aimed at determining whether the patient received appropriate out of-network services. 

I help providers navigate such issues all the time — informed by both my payer and provider side management experience — yet I’m still surprised at the creative ways managed care organizations seek recoups, audits, and claw-backs.

Never ceases to amaze me, our industry.

We need reduction in provider burden, not an increase. Onerous paperwork and requests from payers to conform to various policies and ‘edits’ create an undue strain on our increasingly stressed delivery systems. If I can help, let me know — whether it’s making connections via my healthcare industry ‘contact book’ and/or reaching into my long list of tips/tricks to utilize in dealing with any given issue you, as providers, might be facing.

PLEASE NOTE: Legal issues are complex and highly fact specific and require legal expertise that cannot be provided by any single article. In addition, laws change over time. The information in this posting should not be used as a substitute for obtaining personal legal advice and consultation prior to making decisions regarding individual circumstances.