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One of the biggest claim issues we are now dealing with is our clients getting bills from out of network providers and labs even though they used an in network facility. In the past this rarely happened but it seems some doctors have found out they can make more money by not contracting with an insurance companies PPO network. Even more worrysome is hospitals and out patient surgery centers knowingly allow these providers to work on their patients even though they know the problems it will create.
In the past insurance companies were more tolerant of this abuse and providers thought they had found a loophole to higher reimbursements. Because it became so common, the group insurance companies began following the legal contracts they have in place which allows them to not pay for these procedures as in network benefits. Most policies have a separate deductible for out of network claims which is where these claims get filed. That creates a separate bill for the insured and unfortunately there are no in-network discounts so the provider can bill whatever they want for their services.
Congress and President Trump have promised to create legislation to stop this abusive practice. Of course, they have also promised price transparency and lower prescription costs. We have yet to see those changes and in an election year they need all the Super Pac money they can get.
It is estimated that 20% of all surgeries and hospital stays now have out of network charges with an average cost of $2,011. The scary thing is we are seeing it regardless of which insurance carrier they have and it seems most hospitals are allowing it to happen as well. Even worse, there is very little you can do as a patient on the front end to avoid this from happening.
It is very important for you to understand, this is not the insurance companies fault. This is the hospitals fault loud and clear. They are allowing non contracted doctors to knowingly work on their patients and bill their patients huge amounts they should not owe.
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