My experience has been that since the subscriber holds the relationship with the payer, they need to call to negotiate in network repricing. If they patient is unsuccessful then the provider can do an underpayment appeal on behalf of the member with UCR rates by calculating RBVS and an average of in network rates however because the provider appeals on behalf of the patient they forfeit being able to bill the patient at that point.
Also, when it comes to balance billing there are certain states that have laws against balance billing patients even in the event the provider is out of network.
I have also working for insurance companies processing claims and we would process any lab claims as in network if the ordering provider was in network but the lab was out of network. This was with BCBS so I am not sure if any other insurance companies will process the same way. Also, if the member is PPO member with BCBS they should get in network services anywhere they go.
I need resources and suggestions on how labs can successful obtain payment when out of network. It is very hard to compete with large lab corporations but there is also a need for smaller labs that specialize in particular lab tests. Also, the patient does not have a choice in where their labs are being sent so we want to help them as well and keep a good relationship with our clients.