March 13, 2012

Out-Of-Network Medical Claims Reimbursements – Insurers’ Conduct After Fair Health Data Base Established

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t-forceEDITOR'S NOTE: Healthcare attorney Thomas J. Force continues his discussion on the subject of out-of-network claims reimbursement.

"Insurers mislead and obfuscate in their policy language" - this was the language used by the U.S. Attorney General's Healthcare Industry Task Force back in 2009 in its healthcare report titled "The Consumer Reimbursement System is Code Blue."

So, what has changed since then? The answer to that question depends on who you ask.

The health insurance companies might tell you that they are doing the right thing and have contributed millions of dollars to fund the Fair Health Database, the third-party, neutral cousin of Ingenix. While this is technically correct, the Medical Society of the State of New York (MSSNY) does not think it accurately describes what is happening behind the scenes. As mentioned in the preceding article, the MSSNY found that while New York state insurance companies were funding this new initiative to be more transparent, some were simultaneously using "stealthy methodologies for determining out-of-network payments." Specifically, these insurance companies are seeking to use the percentages of the Medicare fee schedule. That's right - Medicare, the least-reimbursed of all payers with the exception of its cousin, Medicaid.

The aforementioned task force called for necessary reforms, including having "usual and customary" rates determined by an independent third party. It is no secret that Medicare reimbursements are not "usual and customary," so who was the neutral third party who determined that this was the solution? According to MSSNY, this actually will result in "substantially less coverage" than patients were getting under the Ingenix method.

This begs the question: do patients and physicians think anything has changed since 2009? With patients paying higher premiums for the privilege of getting an out-of-network option but then getting stuck with a majority of the physician's bill anyway, the answer is obvious. This in turn influences patients' decisions about which doctors to see. As MSSNY President Leah McCormick has pointed out, the current conduct of insurers seeking to reimburse out-of-network claims based on the percentages of Medicare threatens previously longstanding doctor-patient relationships.

Out-of-network physicians already are feeling the heat from what only can be viewed as a calculated strategy on the part of health insurers to all but eliminate out-of-network benefits in health insurance policies (please see "Out-of-Network Reimbursement: Don't Expect Insurers to Do the Right Thing," available at http://patriotcompli.com/files/RAC_Monitor_Article_-_dont_expect_insurers_to_do_the_right_thing.pdf). Insurers already are refusing to accept assignment of benefits, and this has resulted in checks being sent to patients and not to physicians' offices. Now those out-of-network physicians who are left are facing the probability that they will be reimbursed less than their in-network counterparts. If this trend continues, the livelihood of the out-of-network physician is in serious jeopardy.

What can be done about this latest attempt by health insurers to eliminate the out-of-network benefit option? A preemptive strike against insurance companies is absolutely warranted. This is a call to action to those out-of-network providers who want to reverse this trend. We would like to hear about every case in which out-of-network reimbursements are being based on a percentage of Medicare, Medicaid or the Resource-Based Relative Value Scale (RBRVS).

About the Author

Thomas J. Force, Esq. is a nationally recognized expert in revenue collection techniques, managed-care contracting and appeal strategies. He is the founder, president and chairman of the board of The Patriot Group in New York. As a state- and federally licensed attorney in both New Jersey and New York, Mr. Force has more than 21 years of experience in the healthcare and insurance industries. His success as a Wall Street insurance litigator and his tenure as general counsel for a New York-based accident and health insurance company where he served as chief compliance officer propelled the founding of The Patriot Group. He is co-founder of the Healthcare Reimbursement Attorneys Network, a national association of attorneys who represent physicians and hospital clients. Mr. Force also works closely with the American Medical Association and various state medical associations.

Contact the Author

tforce@patriotcompli.com.

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