Health insurers have limitations on what providers you as the patient can see. Most of us are familiar with network providers and out-of-network providers, and the differential in payments.
Patients are careful to select in patient providers as outpatients, and they have a choice. However when hospitalized and seen by a number of providers the patient loses the option of selecting a provider.
Case in point. A patient is admitted by his PCP (in network), then requires a specialty provider which is usually selected by the PCP.Most of the time the PCP and specialty provider belong to the same network or have an agreed common MSA, HMO or PPO. In those instances the correct billing is automatic. However in cases where a network provider is not available the patient has no choice. This can happen if a patient needs surgery and the anesthesiologist is not in network, or if a patient requires X-rays, or a critical care consultation in an intensive care unit.
Hospitals are careful to accept and join networks in which their physicians are members.
Disputes often arise and a means to adjudicate the billing are important.
A federal judge poked at the government’s defense of a rule that is designed to help third parties resolve payment disputes between healthcare providers and insurers
Federal Judge Jeremy Kernodle heard arguments Tuesday in a case challenging the implementation of a federal law that protects consumers from surprise medical bills. Congress in its infinite wisdom created this law to protect patients.
The No Surprises Act was a win for consumers who found themselves stuck with hefty medical bills after being caught between provider and payer pricing disputes. Patients were sometimes stuck with the remaining balance of a medical bill from an out-of-network provider with insurers paying only some — or none — of the bill. Patients were sometimes surprised by these bills after going to an in-network facility and unknowingly treated by an out-of-network clinician.
With patients shielded from surprise bills, it places the burden on payers and providers to resolve payment disputes when an out-of-network claim arises. If they can’t come to an agreement on reimbursement, payers and providers can opt to engage in an independent dispute resolution process and turn to a third-party arbiter. Each side submits a payment amount, leaving it up to the arbiter to pick one.
Patients are usually confused and poorly prepared to chose a plan which can cover most of their health needs
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