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I'm trying to learn about out of network billing as one position I'm looking at in the Dallas area (eat what you kill) has contracts with some insurance companies and does out of network billing for others.
I've been trying to learn about out of network billing and have gone through the forum and spoke with our billing person (we don't do OON billing though).
Perhaps this thread could help educate forum members.
Not getting into the details, is there a rule-of-thumb as to what kind of collected unit value you can expect in the Dallas area if you have a tenacious billing department?
Other than that I'd like to hear more how it works through the process as I'm pretty clueless. So logistically, how do you do it? (do the patients have to sign anything upfront, what instructions/notices do you send to the patient when you bill them, do the patients have to call their insurance company or sign some document upon receiving your bill, do you get check from insurance company or does patient get check and possibly keep it)?
Can you do this with people that have HMO plans?
Do you get grief for this from surgeons or surgery centers/hospitals?
Do you end up getting any payment from patient or do you usually get enough from insurance company?
Here's my best guess as to what happens from what I've learned (and if I'm way off this is why I'm asking the question!):
1. You do a 5-unit case and bill $200 unit out of network for someone with HMO or PPO
2. You send bill to insurance company. Let's say they pay nothing because deductible is not met.
3. You get no payment from insurance company so you send bill to patient.
4. You instruct patient not to call surgeon or facility when they get bill but rather call your office with billing issues. Your billers instruct them on what they need to do to get bill "reprocessed" by their insurance company toward "in network" deductible such as attesting that "there was no available in-network provider", "they didn't have a choice of anesthesia" or whatever is needed for that particular insurance company
5. Insurance company sees this and contacts billing company making offer to settle account at less than billed rate based on "usual and customary fees" or any other reason they can make up.
6. You rely on your tenacious billing people to get your $200/unit. What is your experience with this?
7. If patient's deductible is not meant then what happens at this point? If the deductible is met what happens? Insurance company pays you, insurance company cuts check to patient?
Thanks!
I've been trying to learn about out of network billing and have gone through the forum and spoke with our billing person (we don't do OON billing though).
Perhaps this thread could help educate forum members.
Not getting into the details, is there a rule-of-thumb as to what kind of collected unit value you can expect in the Dallas area if you have a tenacious billing department?
Other than that I'd like to hear more how it works through the process as I'm pretty clueless. So logistically, how do you do it? (do the patients have to sign anything upfront, what instructions/notices do you send to the patient when you bill them, do the patients have to call their insurance company or sign some document upon receiving your bill, do you get check from insurance company or does patient get check and possibly keep it)?
Can you do this with people that have HMO plans?
Do you get grief for this from surgeons or surgery centers/hospitals?
Do you end up getting any payment from patient or do you usually get enough from insurance company?
Here's my best guess as to what happens from what I've learned (and if I'm way off this is why I'm asking the question!):
1. You do a 5-unit case and bill $200 unit out of network for someone with HMO or PPO
2. You send bill to insurance company. Let's say they pay nothing because deductible is not met.
3. You get no payment from insurance company so you send bill to patient.
4. You instruct patient not to call surgeon or facility when they get bill but rather call your office with billing issues. Your billers instruct them on what they need to do to get bill "reprocessed" by their insurance company toward "in network" deductible such as attesting that "there was no available in-network provider", "they didn't have a choice of anesthesia" or whatever is needed for that particular insurance company
5. Insurance company sees this and contacts billing company making offer to settle account at less than billed rate based on "usual and customary fees" or any other reason they can make up.
6. You rely on your tenacious billing people to get your $200/unit. What is your experience with this?
7. If patient's deductible is not meant then what happens at this point? If the deductible is met what happens? Insurance company pays you, insurance company cuts check to patient?
Thanks!
