Out of Network – by Design or Accident?

So, you have ended up seeing a provider that is out-of-network. Was it by design or by accident?

Patients go out of network for multiple reasons. Sometimes it’s in order to visit their preferred provider. Especially critically ill patients who may want varied provider options than are available within network. When choosing an institution such as physical therapy, skilled nursing facilities, nursing homes or hospitals they may end up being out-of-network. A well-renowned specialist may be out-of-network, but it is very critical to have an expert opinion from a specialist.

In all these cases, going out of network is by design as the patient is making a choice to seek a provider or a facility that is out-of-network with their insurance plan.

It can also be the case that this happens by accident. Most Managed Care Organizations (MCOs) require patients to have their Primary Care Physicians (PCP) refer their patients to specialists. More often they refer to specialists who end up out-of-network for the patients. In many cases, patients go to in-network hospitals but end up receiving emergency services from a surgeon or anesthesiologist not in the network. There have been many cases, where pregnant women have gone to an in-network hospital in emergency labor and the providers who tended to the delivery happened to be out-of-network. This often leaves the patient with unplanned for and larger medical bills.

Some important guidelines to mitigate your risk when going out-of-network:

1. Before going out of network, ask your provider the charges for the visit or procedure and confirm from your insurer whether all charges will be covered. If the charges are not covered by your insurance, you will have a chance to negotiate the price with the provider.
2. Some insurance plans require all out-of-network visits and procedures be authorized or pre-certified. Get the authorization number or pre-certification number before the visit. Many times, your provider office will assist with this process.
3. Some plans pay a certain portion of the government insurance plans such as Medicare or Medicaid. Get a clear understanding of what your out-of-pocket expenses are before you visit the out-of-network provider.
4. Get a clear understanding of what documents are required for filing a claim for out-of-network reimbursements.
5. Get a time-frame for reimbursement from your insurance of all paid expenses.

Finally, we have a solution to get your reimbursement faster without any burden on your time and efforts to get reimbursed. Whether you’ve chosen to see your preferred (out-of-network) provider or you’ve been forced into the situation through an emergency or referral, you can use Oonology to securely submit your claims quickly and easily.