Out of Network? Don't Expect EOBs
Friday, January 30, 2015 09:22 PM

Julie Lenhardt, Sr. Director, Insurance Advocacy

ACA has recently received a number of inquiries regarding out of network providers who are not receiving an explanation of benefits (EOBs) or a remittance advice (RA) for patients covered by plans in which the provider is out-of-network.  While such occurrences are, at this point, fairly unusual--not to mention inconvenient--for the provider, ACA wants to make doctors aware that this may become more common as payers look for ways to cut expenses in the evolving healthcare landscape.  Although it may seem as if payers are violating state regulations regarding prompt payment, that may not be the case.

The reality is that when a doctor is out-of-network, the payer has no obligation to the doctor; its only contractual obligation is to the patient.  Therefore, the patient may be receiving not only the EOBs, but also the reimbursement check for services rendered.  Unless a state has stringent statutes regarding payers honoring valid assignment of benefits, the payer is not required to notify out-of-network providers about claims status.  However, especially for those plans governed by ERISA, the plan is required to notify the patient.

To efficiently reconcile patient accounts and to guard against patients who may not forward the reimbursement to the provider, it may be wise to consider altering your clinic's intake and payment procedures for patients covered by plans in which the provider is out-of-network.  Clinics may need to require those patients to pay for services out of pocket at the time of service and then supply the patient with a superbill so that the patient can submit the claim themselves.  As such, clinics will need to notify the patient up front before services are rendered and have them sign an agreement of financial responsibility that clearly indicates that the clinic will not bill the plan on behalf of the patient and that full payment is due at the time of service.

While providers and staff may be reluctant to do this, it does protect the clinic, and the patient, from carrying unpaid balances.  It also eliminates the difficulty of trying to reconcile accounts as well as the possibility of having to place a patient's account into collections.  To help clinics implement such changes, ACA has a number of member-only resources available in the Practice Resource Center, all of which are fully customizable to meet a clinic's particular needs including a financial policy and a comprehensive assignment of benefits form (which includes an ERISA authorization that allows providers to appeal adverse determinations on behalf of the patient).

Source:  Source:  ACA: In Touch - December 2014