Wiki Provider Out of network, payment going to patients?

[Biller2023]

If a provide is out of network, does Horizon BCBS send payments directly to patients. How can we have insurance send the payment to the provider even if out of network.

 

[andersona1229]

This is something that my lab has to deal with Anthem CO because we're OON with them. My understanding is that there isn't anything you can do; we've exhausted every option we have and they still send them to patients. Patients who have Anthem CO get a notice in their statement explaining that they need to endorse the check and send it and the EOB directly to us or they're responsible for the full balance of the claim. We can't know the adjustments unless Anthem sends them to us in a separate EOB with advice code 100 on it hence why the full balance becomes due. Sometimes we get those informational remits from Anthem and sometimes we don't. If we do get the information from Anthem we only bill them for the payment from Anthem and any patient responsibility left over after the Anthem payment.

I'm still so confused about why patients look at those checks/EOBs and think "Hmm, free money. Let me spend it." Happens all the damn time. It doesn't help that the remits they do send us where they actually send us the payment, they include the entire claim payment on one CPT code instead of the two we billed out. They'll pay both 80307 and G0480 but send a remit with only 80307 and the payment for G0480 combined with it. We can't get them to fix that either because we're OON. I think it's done to make it more difficult for OON providers to either pressure them to become in-network or to stop seeing those patients. Unfortunately, we don't have that option because who the provider orders tests for is out of our hands and it's a closed network apparently.