Medical Billing Training: Determine the Out-Of-Network Benefits


Here are few healthcare training tips your staff can use when they're calling to determine out-of-network benefits and how to handle that.

Most staff is only so accustomed to just dealing with in-network that they need something to use as a guide in order to get them comfortable with the additional questions that they would need to ask in order to determine out-of-network benefits. And especially if you're going to be charging the patient in-network co-pays, co-insurance and deductible, it's important then for you to find out what that is so that you'll know what to bill the patient.

So when they're calling for the out-of-network information, obviously their first question is, “Does the patient have an out-of-network benefit?” And if they are able to do this online, then they would just still need to make sure that these questions are answered to what they're able to find online. If not, they should place that call.

Our expert mentioned in a related health system conference that if the patient has out-of-network benefits, yes, then they go to the next question. Is authorization or referral needed for an out-of-network procedure? What is the in-network co-pay and deductible?

And the reason to ask for in-network is so you can determine what the patient will be billed on the back end after the claim is paid. You're going to verify that the out-of-network address or that they're not using a different billing number for out-of-network claims as per  the medical billing guidelines.

Often times that's at the back of the patient's card but so often patients have old cards that it is important that they get into the habit of asking for the address to send out-of-network claims. A lot of times, out-of-network claims actually go to a third party negotiator.

Often times that's the address on the back of the card or that's the address that this claim should be directed to. When you fail to send them to the correct address or to the correct electronic payer ID, your claim is generally just going to be dropped.

So it's important that your staff be responsible for confirming that they are submitting out-of-network claims to the correct address or the correct electronic payer and they have enough medical billing training to perform their tasks.

And then after the payment is posted, you’re going to want to determine was the claim billed of the charges at the agreed upon discount. If not, you're going to immediately go into appeal. The more consistent you are with appeals, as the payer database comes to determine that you have an established level that you are going to accept less than that, you'll see that as time goes on, your appeals will become fewer and fewer because those databases will be updated with what you're requiring.

On the other hand, if they call and the patient has no out-of-network benefits, clearly authorization isn't an issue, suggested our expert in a healthcare event. Then you're just going to base on your decision. If you've decided that no out-of-network benefits should be directed to a facility where there are benefits, then that's it. Have your scheduler let the physician's office know that that patient will have to be seen, say, at the hospital or at another facility.

If you've made a decision to see patients who have no out-of-network benefits, then they're still going to need to ask these questions, “What is the in-network co-pay and deductible?” Because that's still what you're going to bill the patient.

Medical Billing Training Tip: Verify again the out-of-network address and if the electronic payer ID number is correct. You're going to get a zero payment with a denial saying that they have no out-of-network benefits then at that time, they will refer back to that question regarding in-network co-pay and deductible and send out a bill to the patient for what they would have paid if they were in-network.

Now, we would recommend that if you do make a decision to take patients who do and do not have an out-of-network benefit, that you have an adjustment code set up just for writing off those charges that are affected by a patient with no out-of-network benefit so that you can revisit that very frequently in case you do need to update your financial policy to say that you will no longer take patients without an out-of-network benefit.

So that's definitely a key to review if you did want to start out on accepting all patients within a particular payer. Establish some adjustment codes that will help you to quickly define exactly what's being lost by making that decision so you can make those adjustments quickly that will keep you from going into a revenue slide.
And what will happen initially is that generally the reimbursement is quite a bit higher and so a lot of times things like that don't really get the notice that they should.

But the key really is to be as efficient as possible and so tracking whether or not out-of-network patients who have no benefits which really basically make them charity care cases as is just right for you, it's still important even though your revenue is increased.

You're going to note the patient accounting system. If patients weren't written in probation on it, it definitely should be made available to them.

Our expert suggested in a healthcare webinar that you can post it in the waiting room if you like, just letting them know that as we discussed earlier that particular payers providing reimbursement that's so far below what is generally accepted that you've made the decision to go out-of-network, that this will have no impact on the patient and tell them how they'll still be billed so that again things are upfront with the patient.

And if a patient fails to notice that, at least you did have it there. You provided it for them so that they could be fully informed. Be upfront and open about it. It's probably the key to making sure that your patients are comfortable.

And then, informing your referring physicians' offices if you are a facility and especially their schedulers – whoever's the scheduler of the case is as per the medical billing rules.

Of course, your boarding person or your scheduler, make sure that their dialog includes good information regarding this because if you have a board meeting with your physicians and you tell them about it and they don't pass it along to their staff, it's the staff that actually talks to the patient.

So educating the staff, having someone from your office go in there or from your facility go there and explain to whoever does the scheduling on their end, is going to go a long way towards making this a smooth transition.

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