out of network

  1. B

    Wiki Out of Network Provider Different Charges

    99% sure I know the answer but I'd love to confirm A provider cannot charge different rates for the same service based on what the insurer allows, correct? And this applies to both in and out of network providers, yes? As an out of network provider doesn't have a contract with the insurer I...
  2. O

    Wiki Inconsistent OON Reimbursement Rates (same patient, different claims)

    Hello all. I work for a bariatric surgeon. Recently we have noticed payers like Aetna and UHC reimbursing us at wildly different rates (we are out of network with them). For example, a patient will have an upper endoscopy that is paid almost in full ($11K). The EOB states the reimbursement is...
  3. S

    Wiki Billing with primary and secondary insurances

    Looking to verify the proper patient responsibility to bill them in the following scenario as well as the proper rationale. Primary insurance is a high deductible plan through BCBS and allows $3000.00 to the patient's deductible for a patient's surgery on the $5000.00 billed charges. We do not...
    • sharonc2222
    • Thread
    • balance billing medicare secondary out of network out-of-network patient responsibility
    • Replies: 10
    • Forum: Billing/Reimbursement
  4. M

    Wiki Out of Network Billing Strategies for Labs

    Does anyone have any good suggestions on out of network billing strategies to maximize provider collections either from the patient or payer? My experience has been that since the subscriber holds the relationship with the payer, they need to call to negotiate in network repricing. If they...
  5. C

    Wiki Out of network billing!!

    Hello! Our practice just became in network with UHC as of June. Our effective date was 6/22/18, there was miscommunication with the rep from UHC and the person in our company who signed the contract. The person was under the impression that once the contract was signed and submitted back to the...
  6. B

    Wiki Out of Network Appeals for ERISA plans

    Does anyone have an effective appeal letter which addresses inadequate reimbursement for OON self-funded plans? We have a solid assignment of benefits form, however, we could use some direction with the context of our actual appeal. I understand we have quite a bit of rights under ERISA. If...
  7. H

    Wiki Corrected claim with new prices

    Hello all, I have recently discovered our out of network practice has been under billing for a procedure. Based off our zip code from the Fair Health UCR rates, we should have been billing $1600 for 20553 but have only been billing $800. Can I reach out to the insurance companies and change...
  8. B

    Wiki Appeal techniques for OON claims

    One of our providers recently decided to go out-of-network with major insurance companies. I'm looking for some tips on what to include in our appeal letters to these payers for increased reimbursement. We are mentioning: FAIR Health rates for our geographical area Relevant aspects of the...
  9. J

    Wiki EMPIRE BCBS Emergency Rule OutOfNetwork

    :cool: Ok, I will start by asking the following question: I have a surgeon who did a surgery on an emergency basis on a patient who came in through the edt department of a hospital. He reported his services. He is an out of network provider with Empire. Empire decides to pay him in-network...
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