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*This post was written by our partners at TriZetto Provider Solutions.

With the cost of care steadily increasing over the last decade, healthcare consumers are finding themselves with higher deductibles and out-of-pocket expenses. Most consumers know utilizing innetwork care is the most economical option, but sometimes that is beyond a patient’s control.

You may have heard of the Massachusetts man who received a $3,700 medical bill for the services of an out-of-network anesthesiologist at an in-network hospital. Surprise bills like this occur when patients are seen by providers outside their health plan’s contracted network. A 2016 KFF survey found that nearly 7 out of 10 patients with medical debt did not know a provider was out of network at the time of service. So how exactly does this happen?

Let’s say a patient goes to the hospital for a scheduled surgery. After researching the best specialists, he finds a surgeon in his preferred network. Prior to surgery, he is administered anesthesia. Unbeknownst to him, the anesthesiologist is out of network. To sum it up, the patient was administered a service at an in-network facility by an out-of-network specialist. This is often seen when emergency and ancillary services like anesthesiology, radiology and pathology are subcontracted by a hospital.

Another common occurrence happens when recommendations come into play. Perhaps a patient recently had ACL reconstruction surgery. While the surgeon might be in-network, maybe the recommended physical therapist is out-of-network. If the patient assumes the referring physician would recommend a therapist in network, a surprise bill could appear in the patient’s mailbox after the initial session.

When an out-of-network provider bills for care, the payer is obviously going to cover less of the cost than the patient expects. The remainder will then be the responsibility of the patient. Out-of-network practitioners, not bound by any contractual, in-network rate agreements, are legally allowed to bill patients for the remaining balance, much to the chagrin of patients who thought they were utilizing in-network providers. This practice is known as balance billing.

These circumstances are sometimes out of a patient’s control. Not only is the patient inconvenienced with a hefty bill, but added stress is put on the billing department and practice as a whole when out-of-network providers come into play.

A 2016 KFF survey found that nearly 7 out of 10 patients with medical debt did not know a provider was out of network at the time of service.

Imagine a small dermatology office wants to add specialty providers that will allow the office to offer expanded services like plastic surgery. The same scenario can apply to a mental health facility that utilizes both mental health practitioners and those associated with emergency care. The providers would most likely need to be re-credentialed and claims could be denied if credentials are not processed in time, not to mention the potentially unpaid balances from unhappy patients who receive bills from out-of-network in-house specialists. Another instance where this could easily become an issue is when employers are involved. Perhaps a new job causes a change in insurance, but the employee still visits their family practitioner, not aware that the doctor is now out-of-network.

Unfortunately, this happens more often than we think. So much so that state and federal governments are considering legislation to address the problem. So who is to blame and how can the issue be prevented? Is the onus on insurance companies to proactively help physicians gain credentials and become in-network, or is it on the physician to know what health plans are popular in their region and ensure they gain credentialing with all? One way to help mitigate the issues associated with balance billing is to stay on top of credentialing. If providers are in-network with as many health plans as possible, the likelihood of getting paid quickly and accurately increases. A lot of health plans will even retroactively backdate credentials if applications are submitted timely.

Hiring third party credentialing experts is a way to make sure all credentialing bases are covered. For companies experienced in handling the nuances of credentialing, who are well versed in the regulations and requirements needed by various payers and states, it is a less-stressful way of navigating the credentialing process.

Don't allow the complicated payer credentialing and enrollment process to be a burden on your practice!

Our credentialing partners at TriZetto Provider Solutions have experience working with various payers and providers of all backgrounds. Their team of experts will collect and submit information in a timely manner and perform all necessary follow-up tasks. Let TriZetto lighten your load so you can focus on patient care and growing your practice. For more information or to request a quote, visit the TriZetto partner page.

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