this is a loophole in OON that is being exploited by practice admin.
TL/DR summary - physician practice charges an exhorbitant OON fee for procedure done in an in network facility. the physician practice is supposed to have patient sign a waiver prior to surgery, to bill the patient directly for costs not covered by insurance. the patient does not sign the waiver (probably never gets the chance), and because of that, the insurer is required to pay extra and so it goes to arbitration.
arbitrators seem to tend to favor the physician over the insurer (tho in truth it is the practice that does the billing). the arbitrators (who are also getting paid), have to decide between what the insurer will pay and what the physician practice has charged. if the insurer fees seem unreasonably low, they cant choose a different value. arbitrators may also have a hidden incentive to favor physicians as that generates more arbitrations.
fwiw, apparently some of the physicians questioned are salaried and are not getting the windfall. the practice is.
its admin. its always admin.
(tho it might be the physician who is the admin...)
