In today’s medical world, one of the most common billing issues is Out-of-Network billing for lab charges, anesthesia services, or emergency physician services received INSIDE an In-Network doctor’s office, hospital, or any of a host of other medical provider locations. Unfortunately for most of the population, this equates to many dollars “owed” that should be covered and many hours spent running back and forth between the billing office of the medical provider and the customer service department of the insurance carrier. You will be told at the billing office that there is “no way” for them to know what laboratory is In-Network for your individual plan, or the lab that they sent the sample to, or worse yet, they send you to is the only lab that has the ability to process that certain test and that the insurance company needs to pay up. The insurance company will tell you that you should have chosen an In-Network Laboratory without an exception in place and that the they have no contract with the Out-of-Network provider and there is nothing they can do to keep the lab from billing you.
Well that’s a fine place to be isn’t it?! Well, there’s good news! The steps are the same whether the service is a lab charge, anesthesia service, or emergency room physician. There are even a few other less common services that fit under this umbrella, but being less common, they usually need to meet more specific qualifications to be considered.
**Before Reading Further: Any time you contact a provider or insurer about an issue, be diligent in at least recording the following, both when you make the call and if you are transferred to a new person:
· Date of the call
· Time you initiated the call
· Time you got through to a real person
· Who you spoke with
o First name
o At least last initial
o Agent ID (if possible)
o Supervisor’s name, even if you don’t speak with them
· Questions you asked
· Answers given as closely to verbatim as possible
· If transferred, why?
· Best Practice: Have an audio recorder or an audio recording app on your phone. They ARE recording the call and have lawyers on retainer to defend their side of the conversation, don’t you think it’d be a good first step? J I will leave the choice up to you as far as the app or device goes and am not liable for misuse or abuse of any recorded information by an app’s development company.
First things first, you may have a fantastic provider who will own up to the mistake and help make it right. There’s an equal chance that you may get a fantastic Customer Service Representative who takes the time to scour your plan to see if there are any loopholes on your specific plan that would allow the charges to be paid at a higher rate, or if maybe there’s a provision for negotiation in one of these specific situations.
But don’t fret. If neither of these situations apply, and boy, if they don’t, I’m sorry. There are still several steps that may be taken. Just like what we, at Hand in Hand Patient Advocates, would do after getting nowhere with the billing and customer service representatives; you always have the right to an appeal through your insurance company. **DON’T! I REPEAT DO NOT! EMPHATICALLY AND WITHOUT RESERVE, try your best to get the claim adjusted without the use of an appeal. ** Once you have submitted an appeal, you have sunk your ship of simple adjustment and some plans only allow one level of appeal. Once again, being a member of the average uninformed public, you may not see the importance here. If you don’t follow the process and have the documentation to prove it, further efforts more than likely will not be reviewed let alone return fruitful. Be sure that you’ve exhausted each level’s options before moving to the next. For example, your plan doesn’t allow for considering the charge based on the ordering physician’s network status? Does your plan guarantee that your phone call will be answered in less than 3 minutes by a live person? Did your call concerning this matter meet that requirement? If not, this may be grounds for a complaint, and you may be able to use that as a bargaining chip.
If your plan is “self-funded” or Administrative Services Only, meaning the insurance company does not use their own money to pay out the claims, have you taken the issue to your Human Resources Officer? If you take the issue to the officer and explain the issue, they have the authority, since the money belongs to the company, to authorize the payment or negotiation of these charges for you as well as correct the policy at any time going forward.
Even if the plan is funded by the insurance company, did you take the issue to HR? They may not realize there is such an issue with the way the plan is set up. Your voice and concern could be considered at the company’s renewal meeting with the carrier. In some cases, HR may find the issue so problematic that they act immediately.
Once you have exhausted all options outside of appealing the charge with the insurance company, it’s time to get the ducks in a row, rally the troops, hit ‘em with your best shot……. it’s time to appeal.
You will need to get the steps for your specific plan to submit the appeal and you will want to get a copy of your benefits for the service that is in question. You will also need a copy of your Explanation of Benefits (EOB) from your Insurance Carrier and the Bill from the Provider. As a rule of thumb, I also recommend a letter from both providers involved explaining why they are not in the wrong. Finally, your appeal letter. Though you may spend more time waiting on the letters, statements, and EOB’s from everyone, this appeal letter is what should take the largest amount of attention and time after step one. This letter should focus on why a reasonable, non-biased, third party individual would expect this claim to be paid at the higher level. This is not the time for emotions. We’ll get there, but for the moment, you will need to appeal to the examiner’s logical side. We are talking about money here and these examiners do have to justify to their superiors why they are paying out one penny more than a simple adjustment wouldn’t have corrected. Make a logical argument for the payment of the service siting who made the decisions that led up to the charges AND any facts, figures, or time, ability, or quality restraints that caused the choice to send the work to a Out-of-Network provider. Now that we have explained why the charges should be processed differently, it’s time to play our last card for this round.
YES! Your humanity and experience DO matter to an insurance company, but not until they can justify logically why they should process these charges differently. Now technically, if the examiner is making the decision solely on logic, this statement is false. However, if you get close enough to explaining on a factual level why the charges should be paid, then back it up with your feelings, experience, and appeal to their humanity, there may be a connection made that encourages the examiner to dig into their bucket of tools and help you further. The fact is if they only work based on logic, you can ONLY get an outcome consistent with exactly what you ask for. With an emotional connection, there may be an extra ask that you, as a member didn’t even know to request. With this connection, there is more room for the examiner to go above and beyond.
Some plans allow for a second level of appeal and/or an external review. These appeals will follow the same process as the first appeal but be sure to wait for the official appeal outcome letter. You will want to include these in the next level appeal. These letters may have information or clues as to what you need to include in the next appeal to increase the chance of a more favorable outcome. Do not copy and paste your initial appeal and send it through again as a second level appeal. You may copy much of it, but there should always be more or new information, facts and figures, support from physicians, and personal experience for each level.
Finally, if none of this has been fruitful, there is always your state’s Department of Insurance (DOI). It would not be a bad idea to make another call to the insurance company before going to the trouble of engaging the state department to explain you have exhausted your options with the carrier and will now be working with the state department of insurance. You will almost surely be transferred to a different person who is authorized to speak with people in this situation. Sometimes the insurer will do all they can to avoid a DOI interaction.
Most if not all states require an appeal to have been submitted; remember the conversation about process? You will need to obtain the process from your individual state office and follow their process for submitting a complaint. Be detailed. All your call records, submissions, support letters, and appeal outcome letters if the state allows it. Make sure you send it in an organized fashion. For example, make sure you know how your fax machine sends a fax if that’s how you’re sending it. (i.e. does it send the original right side up or upside down? Does it send it in reverse order?) If sending via email, try to send it in one attachment as you would want it read, or number the attachments if it can’t be sent in one. If you are mailing it, send it like a report and paper clip it together in the order you plan.
Lastly, good luck. We know the journey you are going to be traveling. We know how exhausting and stressful it will be. We feel your emotions tied up in a quarter inch thick packet that’s supposed to comprise all you are as a human, medical pincushion, and member of the insurance company. We promise to be here for you. We promise to pick you up if you run out of steam. We promise to hold your hand from where you are to where you’re going. We’re here for your journey!