Dropping an insurance plan vs OON

[heybrother]

I'm curious if anyone has any insight on out of network billing. I know the letters OON are usually followed by the word "shenanigans". I'm also aware of the no surprise billing laws being passed and that my own state has specific recent legislation concerning it. To be continued. My original plan was that any insurance we canned would just be gone - not accepted. No relationship, cash pay etc.

We dropped Humana. We told established patients we were leaving the network. We told new people calling we didn't accept it. They were paying us 65% of Medicare. We basically lost our entire Humana patient cohort.

Fast Forward. Some patients showed up. Desperate. Same days. Infections etc. They told us they had "Medicare". When they got there they had Humana. We saw them and ultimately submitted the bill to Humana and were paid at 100% of Medicare albeit with a OON co-pay of $65 instead of $10-40. Felt like a win though part of our hatred of Humana was their intermittent defrauding ie. claiming covered services were uncovered every other visit and refusing to pay. Have seen this documented elsewhere on IPED and here in 2019 before I knew who Humana was.

At no point when we were leaving Humana did we ever think about OON billing. I didn't know it was a thing really. Figured in fact that OON was like more complicated and that it still retained some sort of contractual structure. Looked back at a post by @king22 where he dropped Aetna, went OON, and the patients were still seen because they had out of network benefits albeit at a higher copay.

I suspect the defining trait of figuring out how this will work is - (a) does the patient have an OON benefit (b) does the patient have a Medicare advantage plan.

For Medicare advantage plans it seems like based on my n=2 that if you see a Medicare Advantage plan patient OON (and they have a benefit) then you are still capped at the Medicare Fee Schedule (that's fine).

My partner and I unfortunately have different rates for United Medicare Advantage with his services being paid higher. I'm skeptical based on our rates that my partner will want to put this insurance to the test, but I will start looking at patient's insurances to see who has out of network benefits. At 65% Humana was a slam dunk. With my partner getting 100% of E&M/CPT messing with this rocks the boat for him. The easier thing would be to route all future patients with United to him though he would object to that.

For United commercial - I believe this is where it gets more complicated because they are not MA. Again, my initial intention was to simply drop them. However, I suspect we'd still have patients who would ask to be seen out of network albeit I don't think it would be that many people.

According to commercial company websites when they are telling their clients not to go OON - essentially they tell them they
(a) will likely have a much higher copay
(b) they will have a much higher rate ie. lacking the contractual reduction
(c) and they'll have a much lower co-insurance ie. instead of the insurance paying 80% it might pay 40%.
(d) and finally they are in danger of being balance billed above whatever insurance agrees to pay

However, when you go the provider "Out of Network pages" it seems that United uses rates supplied by "data" companies to try to control the value of out of network services even when they don't have a contract with you ie. they have data on what providers got paid everywhere and they use it to still pick a value.

I suspect we will have no idea how this will play until we try it. Our fee schedule rates in general are I think pretty reasonable. Like pretty regularly $1 above whatever Blue Cross or some odd ball insurance pays. I know whenever I talk to another podiatrist I can find someone who will tell me a fee schedule value that is insanely low, but our fee schedule rates aren't what I think of when I think shenanigans.

Anyone have an insight? Anyone drop a commercial plan before and still see people OON?

---

Members don't see this ad.

 

[air bud]

 

[king22]

I only have experience on OON billing when it come to MA plans. So far it's been a positive experience. I still see most of my Aetna MA established patients (established prior to leaving the network) and continue to see new ones. I've noticed that a growing portion of my Aetna MA patient's have employer subsidized MA coverage. Most of these plans have no difference in cost sharing between OON and IN.

As for Humana, I'm still fascinated at the vast differences in fee schedules. Humana's standard contract in our area, for both commercial and MA products, pay 100% of the current medicare fee schedule. I'm currently in an enhanced contract which pays 102%. Humana still plays the same games (deny reimbursement for services) here. Not really a super big deal for me since all we do is send in notes and we get paid.

 

[zircushio]

I don't have anything to add to this at all, but I am greatly interested in everyone's experience in OON patients only as I am starting a position which is OON exclusively. I guess I will be able to add to this conversation in a few months

 

[heybrother]

I tried to do some reading on this last night. Unfortunately, most of the internet topics about this pertain to emergency care / hospital related / balancing billing issues ie. emergency surgery and the anesthesiologist is out of network.

The heart of some of the shenanigans appears to be surgery centers and locations which tried to run 2 sets of books. Essentially, you bill the insurance company for out of network care an and expose them to the full pricing structure to see what they will pay. Then whatever component the patient would have owed you write off. Obviously not everyone writes it off since balancing billing exists, but if you expose the insurance company to the full price and write off the patient component that can be a violation of the false claims act. More on that at this link.

Out-of-Network Billing: Necessity or Nightmare? - Eye Care Leaders

Out-of-network billing could be a big liability for your practice, leading to increased denials, delayed revenue, and even charges of false claims.

eyecareleaders.com

One of the other interesting things is - do out of network claims get submitted in the same process as in network.

In an article from 2016 - a therapist discusses OON billing. They describe 2 different ways of billing. In both strategies you collect your full fee up front. Then you either (a) give the patient a superbill to submit to their insurance (b) or you submit the OON billing for the patient directly to the insurance company but you instruct the insurance to send the payment to the patient instead since you already were paid. The problematic aspect presumably of this is you have to inform the patient that they may get nothing back since (a) a portion of their "reimbursement" would be eaten up by a larger out of network copay and a larger deductible (b) insurance often still enforces a contractual maximum value for the service so even though you charged $200 for the visit the insurance still determines the value to be worth $160 and then works down from there subtracting copay etc.

Obviously collecting full free up front and putting the effort of collecting reimbursement on the patient comes with its advantages though most people are likely not used to this strategy. Historically it seems like most OON providers have likely relied on a structure of simply billing as large a value as possible and seeing where the chips fall, but this plays to insurance company strengths ie. continuing to try and contractually reduce the value of the service through databases above ie. see Ingenix, Fair, etc.

To me the heart of safe OON billing is likely - create a fee schedule that actually represents what you want to be paid instead of a wish list because if you create a wish list and then start writing patient values off you could finding yourself in trouble.

 

[air bud]

The surgery center OON was my experience in residency....let's just say these were some unscrupulous actors even by podiatry standards....

 

[DYK343]

The worst is inpatients I get consulted on and then considered OON. My billers take care of all that for me but its caused a lot of headaches for the patient who has no choice who comes in the room and says "we gotta operate tonight - no time to wait". Then get hit with a massive bill because im not in network.

 

[zircushio]

The worst is inpatients I get consulted on and then considered OON. My billers take care of all that for me but its caused a lot of headaches for the patient who has no choice who comes in the room and says "we gotta operate tonight - no time to wait". Then get hit with a massive bill because im not in network.

Can you go into this a little further? I'll soon be OON, curious how much your reimbursement is vs. in network for hospital consults. We had a guy here who was purely OON and would charge OON prices to their insurance because it "was an emergency and they came to the hospital" but apparently they are cracking down on that? Unsure.. but then again we had plastic surgeons who came with credit card readers for face lacs that parents demanded the plastic surgeon do for their kids.

 

[DYK343]

Can you go into this a little further? I'll soon be OON, curious how much your reimbursement is vs. in network for hospital consults. We had a guy here who was purely OON and would charge OON prices to their insurance because it "was an emergency and they came to the hospital" but apparently they are cracking down on that? Unsure.. but then again we had plastic surgeons who came with credit card readers for face lacs that parents demanded the plastic surgeon do for their kids.

My billers take care of most of this for me but there are times when insurance doesnt agree to pay the extra OON costs and its left to the patient - which ultimately most of them can not afford and its non paid service. Doesnt happen that often but it does happen. Luckily the MSG I work with takes most insurance plans in the area.

 

[Feli]

I think it's fine (OP idea).
No doc, pod or otherwise, should take Humana... probably not Molina either. MCA is obviously a good-with-the-bad thing to get MCR.
It is fine to be OON with any or all... or make them cash pay, etc (if you are busy enough and it works in your area).

This is part of why call is such a nightmare... not only is podiatry almost certainly NOT paid for call (unless it's paid indirect as a req part of hospital FTE contract), but we are likely to do much work on ER or consult pts for little or no pay. The per-hour on that stuff is pitiful compared to office unless maybe a DPM sets up many inpatients to round on in one swoop at a bigger hospital. Ortho and GS and etc do ok since they get paid well nightly for call and get whatever the bill/collect on CPTs as gravy... DPMs, not so much. If I ever have a Int Med or ER doc who consistently calls me for Molina and MCA, I will chat with them, but that's thankfully not a huge issue in my demo... mostly commercial or at least MCRs.

The surgery center OON was my experience in residency....let's just say these were some unscrupulous actors even by podiatry standards....

Yeah, this is common for surgery centers in some areas. I don't know a lot, but I sure wasn't paying for a practice based on that part of the income... seems to be a house of cards.

 

[Creflo]

I don't file anything except original Medicare. The rest are self pay for my fee schedule and I give them a bill to send to their insurance company if they want. About half of my self pay patients want the bill. I explain that I won't assist with the filing beyond just giving them the bill. One humana patient sent their bill in every time, and almost every time Humana sent me a "credit card" payment. I never "cashed" the payment. I told the patient that Humana tried to paid me instead of the patient, and it ended up that the patient spent hours on the phone with Humana trying to straighten it out. I had to correspond with Humana to explain to them that they should not have paid me, and I never cashed their payment, but in their system they believe that by sending me the credit card payment, they think I "cashed" it, so on their records they paid me and I took the money (which I did not). So for fear of being on their list as owing them the money back, I had to call them and clarify this so they would not stop payment to me on original medicare plans where they are the supplemental/secondary payer. I had to tell the patient that the only way I can see them anymore is self pay and I will not give them an invoice to self file because Humana is incapable of handling it correctly and I don't have time to deal with it.

 

[zircushio]

I don't file anything except original Medicare. The rest are self pay for my fee schedule and I give them a bill to send to their insurance company if they want. About half of my self pay patients want the bill. I explain that I won't assist with the filing beyond just giving them the bill. One humana patient sent their bill in every time, and almost every time Humana sent me a "credit card" payment. I never "cashed" the payment. I told the patient that Humana tried to paid me instead of the patient, and it ended up that the patient spent hours on the phone with Humana trying to straighten it out. I had to correspond with Humana to explain to them that they should not have paid me, and I never cashed their payment, but in their system they believe that by sending me the credit card payment, they think I "cashed" it, so on their records they paid me and I took the money (which I did not). So for fear of being on their list as owing them the money back, I had to call them and clarify this so they would not stop payment to me on original medicare plans where they are the supplemental/secondary payer. I had to tell the patient that the only way I can see them anymore is self pay and I will not give them an invoice to self file because Humana is incapable of handling it correctly and I don't have time to deal with it.

Can you discuss your business model a little more? What do you routinely see, do you see a lot less patients vs. typical in network? How comparable is your reimbursements, etc? Just curious

 

[trophyhusband]

One humana patient sent their bill in every time, and almost every time Humana sent me a "credit card" payment. I never "cashed" the payment. I told the patient that Humana tried to paid me instead of the patient, and it ended up that the patient spent hours on the phone with Humana trying to straighten it out. I had to correspond with Humana to explain to them that they should not have paid me, and I never cashed their payment, but in their system they believe that by sending me the credit card payment, they think I "cashed" it, so on their records they paid me and I took the money (which I did not). So for fear of being on their list as owing them the money back, I had to call them and clarify this so they would not stop payment to me on original medicare plans where they are the supplemental/secondary payer.

So my wife is OON in a completely different specialty but she used to get those high fee scam cards from the insurers as well. We asked around and folks told us to put a note on the superbill that she doesn't accept assignment and to reimburse the patient so we did. So far so good, haven't had an insurer try to reimburse her in over a year.

 

[heybrother]

Interesting so far. I'd essentially describe Creflo and Trophy as simply "cash only" in the sense that the patient is making a full fee schedule payment. This is somewhat of an artificial distinction since you all are OON but you aren't attempting some sort of strategy to maximize out of network benefits. You are simply being paid and then the patient can pursue the assignment of Your Price - "Max Benefit Value of Service reduction" - copay X 40% out of network coinsurance etc.

 

[trophyhusband]

Interesting so far. I'd essentially describe Creflo and Trophy as simply "cash only" in the sense that the patient is making a full fee schedule payment. This is somewhat of an artificial distinction since you all are OON but you aren't attempting some sort of strategy to maximize out of network benefits. You are simply being paid and then the patient can pursue the assignment of Your Price - "Max Benefit Value of Service reduction" - copay X 40% out of network coinsurance etc.

Correct, again different specialty but the terms most often used are cash pay or self pay. Still technically OON but if you don't electronically submit your bill to insurers or clearinghouses HIPAA doesn't apply to you which is one of the big reasons for doing it.