Paying Out of Network claims based on the Medicare Allowable Fee Structure is the new U & C

Has anyone gone to a non network doctor recently? Chances are you will be paying quite a bit more than you are used to. This is because many of the insurance carriers are reimbursing these charges based on the same allowance as Medicare perhaps adding a small percentage. This can cause quite a balance due.

What can you do? In this environment, doing a little bit of homework can go a long way. It is important to know the provisions of your plan and how out of network providers will be reimbursed. If you must use an out of network provider contact them prior to services being rendered to find out what they will charge. You can then contact your carrier to see how the charges will be reimbursed. Of course the preference is always to use the network but when you can’t you do not want to be caught off guard.

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4 Responses to Paying Out of Network claims based on the Medicare Allowable Fee Structure is the new U & C

  1. Heidi Sidley says:

    Thank you for this insightful and timely information. I assume the best way to access plan provisions is by calling the number on our health card or visiting the carriers website? Is there a reason some doctors chose to be in some networks and not others?

    • AskMaxon says:

      Thank you, Heidi. Doctors may avoid joining a provider network for many reasons. A few that quickly come to mind are: The reimbursement rate is too low; they have to wait too long to receive their money; there are too many rules and restrictions in handling patients for example they do not want to give referrals and lastly they may be reimbursed on a per capita basis versus fee for service. I am sure if you asked a doctor, you would get many different answers. This just provides a few.

      You should be able to go online or call the carrrier to obtain answers to benefit questions. If you call try to be specific. You can always call your broker for help, if you have one.

      Of course, there are services like AskMaxon when you get frustrated and aren’t sure you are receiving correct information.

      • Tina Mancuso says:

        Good information. Ask before you incur the expense. In general, hospitals and physcian groups negotiate with the variouss insurance carriers for an accptable reimbursement rate for their services. If there is a dispute, they may temporarily suspend participation with that carrier. An important rule when making doctor appointments, verify that they accept your insurance plan not just your insurance carrier. For example, a doctor may accept a PPO but not an HMO. And first and foremost, know what your health plan covers and DOES NOT cover.

  2. Ernie M. says:

    This information is both hepful and timely. From what I’ve been reading the “the balance bill” will be even higher under Obamacare so every effort should be made to go “in network”!

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