Is It The Insurer’s Responsibility To Pay Out Of Network Physician Providers?

The answer is an obvious “yes”. But most medical practices tiptoe around the out of network issue. It could be because reimbursement policies and healthcare regulations are so complicated; everybody shares a vague discomfort when it comes to medical reimbursement.

The AMA in a recent post encourages medical practices to make the insurer accountable for out of network physician reimbursement. One of the key points the AMA emphasizes on is that medical practices should have a clear cut fee schedule.

Over-billing Controversies !

There have been several controversies surrounding the medical billing practices of out-of-network providers. Patients have cried foul over grossly inflated bills. A physician in California billed a patient $30,000 for a gall bladder removal procedure. The Medicare rate for the surgery is as low as $778.

It is a question of integrity…

Physician practices need to stand up for their patients and for fair medical billing practices. They will have to stand up and intervene to curb the menace of over-billing  And, the browbeating of helpless patients, into paying huge, bills. It is important that physicians are aware of how the insurer calculates the charges for out of network care.

The need for patients to get more involved !

 Providers are certainly pushed to a corner when the affable patient who was okay with the fees, suddenly makes a hue and cry about the charges. The major reason for conflict seems to be the patients’ poor understanding of the billing process. Some patients don’t even know that out of network providers can be more expensive than in network medical care providers.

Unless it is an emergency patients should explore and learn about insurance plans, treatment options and cost of service. Patients need to be aware of their responsibilities and understand EOBs.

The need for more transparency !

The healthcare industry is in an unhealthy state as everybody has a vague feeling of distrust towards one another. Better and more open communication, among-st healthcare practices, physicians, patients and insurers is the only cure for this “pointing fingers” epidemic.