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EMPIRE BCBS Emergency Rule OutOfNetwork

  1. Cool EMPIRE BCBS Emergency Rule OutOfNetwork
    Medical Coding Books
    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 rates since they are claiming the patient didn't have a choice to choose an in-network provider and that is why they are doing so. This does not sound right to me. They did it several times. I couldn't find anything in their policy documentation regarding this. The place of services was emergency room. Does anyone have any input regarding something like this?

    Any input will help.

  2. Default
    Quote Originally Posted by japonte1962 View Post
    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 rates since they are claiming the patient didn't have a choice to choose an in-network provider and that is why they are doing so. This does not sound right to me. They did it several times. I couldn't find anything in their policy documentation regarding this. The place of services was emergency room. Does anyone have any input regarding something like this?

    Any input will help.
    Most, if not all, insurances will pay for in-network on an EMERGENCY basis if the doctor is out-of-network. However, as stated, it has to be an EMERGENCY basis. The scenario you provided as stated was an EMERGENCY basis, so YES they will reimburse the surgeon as in-network. I do not understand what you are confused about. The patient, in an EMERGENCY, does not have time to find out which doctor is in-network... they need IMMEDIATE attention. The insurance companies realize this and that is why they have this clause. Hope this helps.

  3. Default
    Hi,

    Thanks for the feed back. However, just as a quick note and clarification, I did not question whether the patient should have been taken care of or not. Obviously it is top priority. In retrospect and in reviewing your comments, I can see your point. The patient would have been left with a responsibility if they paid out-of-network benefits, which in this scenario (emergency), may have been the case. I guess this wouldn't be fair.

    Sometimes we need feed back to look at things correctly. Thanks

  4. #4
    Default
    Quote Originally Posted by japonte1962 View Post
    Hi,

    Thanks for the feed back. However, just as a quick note and clarification, I did not question whether the patient should have been taken care of or not. Obviously it is top priority. In retrospect and in reviewing your comments, I can see your point. The patient would have been left with a responsibility if they paid out-of-network benefits, which in this scenario (emergency), may have been the case. I guess this wouldn't be fair.

    Sometimes we need feed back to look at things correctly. Thanks
    I think I get what you're asking - Are you questioning the allowed amount? Since you're not contracted (i.e., in-network), how did they apply a network discount, which you never agreed to accept, to a payment that you're supposed to accept as payment-in-full?

    They short answer is, the discount isn't a participating-provider contractual write-off; more than likely, it's the reasonable and customary rate for your area - you should ask them how they determined the amount to be sure, though. They'll tell you where the number came from. Depending on their negotiating skills, different providers have different contracted allowable amounts for the same services with commercial payers - there's not a set price that they pay everyone, like there is with Medicare and Medicaid.

    When you hear the phrase "in-network" in situations like this, it pertains to the patient's benefit category, not the provider's fee schedule. This being paid in-network to an out-of-network provider, just means that they sent a check to you, instead of denying the claim or applying an outrageous amount to patient responsibility. It benefits the patient more than anyone else, but it's a good thing for you, too. Insurance reimbursement is guaranteed payment; would you rather get a portion of what you charged from the insurer, or would you be happier sending 100% of it to collections later, if the patient doesn't pay? You can collect the rest from the patient, in many cases.

    Hope that's what you needed!
    Last edited by btadlock1; 04-08-2011 at 10:19 PM.

  5. #5
    Default This is from Anthem, but it's likely applicable to Empire, too...
    "Because there is no Provider contract or participating agreement, a Non-Participating Provider has not agreed to a reimbursement rate for services provided to members. Therefore, absent a regulation or law, the Non-Participating Provider can bill the member for the difference between the amounts they charge and the Non-Participating Provider Reimbursement Amount. Members are responsible for paying Non-Participating Providers this difference. Depending on the service, this difference can be substantial. "

    http://www.anthem.com/wps/portal/ca/...nt&rootLevel=2

  6. Talking
    Thank you...

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