Healthcare providers and patients are caught between a rock and a hard place when it comes to commercial insurance. Patients pay higher premiums to their health insurance carriers, so that they have more choices when selecting a medical provider. At the same time, insurance carriers punish doctors and medical facilities for not being “in-network.” Generally, the patient pays higher deductibles and co-payments when procedures are performed “out-of-network.” Also, going out-of-network often results in penalties being imposed on the patient. So, the patient pays for choice and then both the patient and medical provider are punished for the exercise of that choice, which the patient already paid for.
Providers are also challenged when it comes to pre-certifying procedures in the context of commercial insurance. Often, procedures are performed after being told no pre-certification is necessary, or after receiving authorization only to find out later payment is denied as not medically necessary. It is difficult for a medical provider to grasp—and rightfully so–that they will not be paid for a procedure by a carrier when that carrier authorized the procedure.
Insurance companies commonly set their own reimbursement rates at levels substantially lower than what is expected in the medical community, and medical providers often have little choice but to accept these low payments. Many insurance plans, moreover, are very difficult to obtain, because carriers do not readily send them to medical providers, and when they can be obtained after protracted effort, they are often vague and border on the incomprehensible.
Callagy Law has spent a tremendous amount of time and expense fighting for out-of-network providers, and we will continue to do so.
Original Story: http://ow.ly/GbsTG