Participation In Care By Out Of Network Providers, Vendors, Facilities

Jul 3, 2012 | Uncategorized

Participation In Care By Out Of Network Providers, Vendors, FacilitiesThe health plans are increasingly putting pressure on providers (especially surgeons) to utilize IN-network providers, vendors, facilities, etc.nnOne Example:  For years, it has become common place for Out Of Network (OON) surgical assists (many of whom are SA’s or C-SA’s) to get a hold of the surgeons bill for a surgical case and send out claims for 100% of the surgeon’s fee (the total fee prior to any contractual discount or even multiple procedure discounting) on the cases where they participate as first or even second assist.  Some states have laws that force the health plan to hold the patient harmless to bills if the surgeon and the facility (or some combination) is IN-Network.  The SA’s and some “creative” billing services are capitalizing on this loop hole to send in OON bills at 100% of charges.  In many cases they actually get paid these amounts.   Making it more profitable to be the SA than the actual surgeon!   Imagine having virtually no-risk, no overhead, no staff to pay.  You just show up for the case and get up to 5 -10 times what the actual surgeons gets for the case!nnWell, as we have always suspected, the health plans are finally saying NO MORE.  In addition, many patients are not aware that there is an OON provider taking part in their case until they (the patient) gets a surprise, a huge bill – if even just the OON Co-Pay from someone they don’t know, never met, didn’t know was going to be in the case.  The other un-intended consequence is that the total cost of a case (something that one surgeon is measured against others by) has astronomically gone up due to this practice.  The surgeon, who is IN-Network gets a black mark because the overall cost of his/her cases is affected by the charges and network status of everyone involved.nnSome health plans are filing suit, others are forcing their In-Network surgeons (in the case of the OON SA assists) to make their patients aware of the use of an OON provider.  We recently have seen United institute this for the use of OON facilities.