Currently, out of network claims are much higher than standard in-network ones. There are plenty of reasons for this, but what matters is that lawmakers are trying to simplify the process by matching the rates of both sets of claims. If that legislation goes through, everyone, from commercial health insurance companies to patients, will pay less for out of network care. On paper, this sounds great. However, it will create many complications, both for the hospital billing staff (and the workers at the insurance companies who need to approve and pay the claims) and the hospitals themselves.
What Hospital Leaders Believe
According to the experts, “Using already highly discounted rates as a payment standard for out-of-network providers would dramatically slash reimbursements to hospitals, emergency rooms, and healthcare clinics. Those lower rates would, in turn, lead to a loss of quality practitioners and healthcare staff, which would result in reduced patient access to care, and ultimately, higher prices.”
Also, as it turns out, “these in-network rates already have been highly discounted, so using them as the basis for out-of-network rates would result in hospitals, emergency rooms, and other vital health-care clinics seeing their reimbursements slashed dramatically. Reduced reimbursement rates for hospitals inevitably would lead to a loss of quality practitioners and health-care staff, which would result in reduced patient access to care and, ultimately, higher prices. For many hospitals in our area, that financial burden may be too much to bear.”
In a country where healthcare facilities are already operating on a small financial cushion or even month to month, this could be devastating.
Other Complicating Factors
In addition to making it difficult for healthcare facilities to pay their bills, other complicating factors could arise. For example, what happens when the billing department sends out claims that were supposed to be paid at the old rate (based on the date and time of care) and the commercial health insurance agency refuses to pay them, thinking that those claims should be billed at the new rate instead. As you can imagine, chaos can ensure, adding to the billing department’s workload and increasing the amount of unpaid claims that the hospital or clinic is forced to put into their debt bucket. When that amount gets too high, very bad things can happen, such as having to cut services, layoff key staff members, and possibly close their doors.
Filing Federal ERISA Appeals
If your hospital or clinic has a number of aged out of network claims that commercial health insurance companies simply haven’t paid, and those claims have exhausted their state-level appeals, it’s time to do something about it. Contact us – Healthcare Revenue Solutions. Our trained employees know how to file Federal ERISA appeals and we can clear up those aged claims. Reach out to us today!