Repricing on Health Insurance Claims

February 15, 2020 Stan

We have all heard the stories of the emergency room claim that cost $10,000 for a broken thumb, or the person who had to file bankruptcy from the huge bill while using a network outside of their HMO. These stories have been the fuel for arguments on what should be done with our Nation’s healthcare system. The truth is these stories occur more than most people realize, and many have misconceptions on how this happens. This is why it is crucial to have the right billing network to take advantage of most favorable, predetermined pricing available.

Lets take a look at a couple of scenarios where one person is stuck with a high medical bill and the other is protected. Suppose that two people walk into an emergency room for the same injury, one having adequate health insurance and the other having none. The emergency room is going to immediately know that each patient will be billed differently. The person with the right network billing plan will be able to take advantage of a nationwide network, allowing predetermined pricing for most any medical condition you can name. The other will be at the mercy of what the emergency room decides to charge. Depending on the medical condition, the difference of what is paid out could be upwards of tens of thousands of dollars. The catch is, in order to receive this predetermined billing you must have access to the participating billing network.

When you take a closer look at how these billing networks work it becomes clear where you may be exposed, especially on smaller networks. No one knows this better than the self employed and those who do not get insurance offered through work. When an individual purchases health insurance on the exchange (Healthcare.gov), the only network options available in Texas are HMO, or restricted networks. These networks are formed for the insurance company and the medical institution to share losses, while hoping to bring in excess volume of patients to offset the claims. Even these smaller type of HMO networks can have big holes in their billing networks. For example, if an individual has a surgery within their HMO network they may still have an unpleasant surprise when the final bill comes. Although their surgeon is likely covered, both the anesthesiologist and the surgical tools rented for the surgery might fall out of the billing HMO network, causing thousands of dollars to be paid by the patient. You guessed it, not a word of warning, just a bill that the health insurance will not cover well after the surgery.

The only way to avoid a small HMO network pricing trap is to take advantage of much larger billing networks, allowing you to avoid the uncovered pitfalls. These larger networks, or providers, can have hundreds of thousands of doctors and medical institutions participating coast to coast. Many of these nationwide networks make it mandatory for their preferred discount to be the primary, or front runner, method of billing, protecting the patient’s financial interests from any threat of overpricing. In fact, these predetermined pricing modules are so accurate some insurance companies form their coverage to mirror the preferred billing, therefore limiting the out of pocket expense by thousands of dollars. Those who utilize this service can rest easy knowing that their interests will be protected moving forward from the right billing network with unrestricted networks nationwide.

Although these billing network giants are elusive in today’s ACA health insurance environment, they do exist across the nation, Texas included. In fact, I have helped dozens and dozens of clients take advantage of these unrestricted networks over the last few months alone, at much more reasonable premiums than ACA policies. It is important to consider the network billing plans when choosing the right heath insurance plan for your family, especially for those who do not qualify for a subsidy (Federal income credit given to those with limited financial means). It is extremely important to speak to a health insurance professional who has access to these unrestricted billing networks, in order to protect your financial interests.