Hello. Can someone help me? Our office is out of network with a few insurance companies which causes us to request a Gap Exception/Waiver , which authorizes us to be in network for a certain procedure they need. My question is, are we able to balance bill after insurance pays? The explanation of benefits usually states the patient responsibility is zero or just the copay, although I am being told I can tell the insurance company we want to balance bill them when requesting the gap? I thought the reason to get the waiver was to minimize patient responsibility?
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Tag Archives: Network
Medicare- UHC and Optum run around ( NY Out of network Providers)
This isn’t a rant as much as much as trying to find anyone having the same problems and maybe come up with a solution to the issue.
We are Internists that see patients in the office as well as in the hospital. We are finding 3 out of every 5 UHC claims are coming back requesting the medical records to process the claim. It doesn’t matter if it is an office visit or an in patient hospital visit. (thankfully we have found a new tool on their website to stay on top of these paper requests before they even get to us. Unfortunately it seems more requests for medical records end up on the UHC mail room floor than the ones that actually get to us).
Once we know they want the Med Recs we send them immediately. With UHC it seems you send the Med recs to UHC they forward them on to Optum. Optum then reviews, gives the ok, and then sends notice back to UHC to process and pay the claim. UHC pays the claim and all is right with the world. <—— That is the dream scenario.
(what actually happens)
– Med recs are sent to UHC
– UHC forwards to Optum and then that’s it.
– Many cases we will call after some time to find the claim status. We are usually told by UHC they do not have the med recs. We have uploaded them to their web site so we know for a fact they have them….
– We give them the ticket number and they eventually find it and tell you to call optum because Optum should have reviewed it. Then we get an image number from UHC to give to Optum.
– We call Optum and they say they don’t have the claims
_give Optum the UHC image number and they eventually find the claim and say oh yes we reviewed this and sent it back to UHC to process…. you need to call UHC.
– Call UHC back and start from scratch… we don’t have the med recs.
– After going around and around they finally say OK we will send the claim back for review give us 15-30 days to process.
– Working the rest of our AR lists we call back in another month or so and start at the beginning once again. Usually the final outcome is we get a denial for Timely Filing.
– NOT giving up we file an appeal as directed , faxing to the escalation unit… again we have proof they have received it.
– Another denial for TF
– After 2 appeals we are going in circles and wasting more time
*** Being out of network we do not have a provider advocate to help us. We have even tried to submit to the NYS insurance commissioner and been told UHC is not a NY company and they can not help us. Is anyone else having this problem or found a way to avoid this entire run around??????
Thank you
Out of Network Billing Strategies for Labs
Does anyone have any good suggestions on out of network billing strategies to maximize provider collections either from the patient or payer?
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.
Out of network billing!!
Hello!
Our practice just became in network with UHC as of June. Our effective date was 6/22/18, there was miscommunication with the rep from UHC and the person in our company who signed the contract. The person was under the impression that once the contract was signed and submitted back to the UHC rep, we were in network and able to see patients. We ended up finding out that the effective date was never discussed and we shouldn’t have been seeing UHC patients until 6/22… is there a way to appeal the claims from prior to 6/22/18? Do we have to set it to patient responsibility since we were technically still out of network?
Any advise helps!! A UHC rep told us to just resub the claims after the effective date but we still havent received anything back for the dates prior to 6/22.. not even denials.
Guidelines for billing the patient for in and out of network providers
Does anyone know the guidelines for billing patients if you are an in-network or out-of-network provider?
Can you give the patient a discount, or must you bill them the same amount as the insurance company?
Can you give the patient a discount, or must you bill them the same amount as the insurance company?
Region 1 – Stay Connected and Network
Staying connected and networking can be very valuable tools when advancing your career within the coding industry. Often, we turn to each other for advice when it comes to each other’s coding expertise and by seeking advice we are doing a few things. One, we are showing that we are humble and that we do […]
AAPC Knowledge Center
Hospitalist out of network
I’m hoping someone can help me about a debate at my job.
We are out of network hospitalists group &
some say since patient is seen in hospital, then we should get paid in network ( which I know is not true, since we have no contract with insurance)
others say since we are out of network, we can bill patient the balance.
I need to find somewhere in writing so I can explain to staff. Can someone provide me with rules/laws in florida to when we can balance bill patients.
Thank you 
Recoupment for Out Of Network
Hello to all, this is my first time asking a question on here. Please be kind. I work in a Multi specialty out of network office. We do both Chiro and Medical. Question is, Are insurance companies take a recoupment back from future pt payments, or can they only send the request and have to wait until it is paid? Humana is taking from us. Just need some clarification as I can not find anything on this. Thank you for all your help.
~Jenn CPC
I would like some input on TCN -The Coding Network
I am researching this company as I applied to 3 positions and received 2 separate emails with links to take their proficiency tests. I’ve seen some very mixed reviews concerning the tests (including the fact that many do not even hear back from them with an offer to test) and would love some recent insight into the process and the company if anyone has dealt with them. The test does seem unprofessional & unclear, and from what I have been reading unfairly graded. I want a remote position and I plan to be very picky about who I choose, so before I stress over these tests, I wanted to reach out here. Any input is appreciated!
Tina Smith COC, CPC
Medical Billing Service looking to network
Hi. I own a medical billing service and am looking to network and connect with other medical billing services. I look forward to hearing from you!