Most people who have health insurance are at least somewhat familiar with the term ‘out-of-network.’ Those who work in the health insurance industry likely explain this concept to members often. While many people know that out-of-network refers to providers and services that are not covered under a person’s health insurance plan, it’s not always that easy.
There are an increasing number of loopholes that can change the meaning of out-of-network depending on the situation. For example, let’s say a member visits the emergency department of a hospital, and the medical staff determine the member needs more advanced care than they can provide. They then transfer the member to another hospital that can offer them appropriate treatment. When this happens, the member will not enter the facility through the emergency department. Instead, they will be admitted to the hospital itself, since the other facility’s staff have determined what the member’s medical needs are.
When the member becomes a patient in the second hospital, their case is then categorized as an inpatient admission. This type of hospital admission is not considered an emergency. As a result, this aspect of the member’s stay is likely to be overlooked by insurers reviewing the member’s medical records, especially if they do not have the records from the initial emergency department visit.
There is existing legislation that aims to clear up inconsistencies in cases such as these. Federal laws such as the No Surprises Act, along with some state laws, exist for just this purpose. In particular, federal legislation disallows providers and insurers alike from billing members for out-of-network fees generated from emergency care. However, it’s essential for providers to not only notify patients at out-of-network facilities, but also explain the fine print that details this nuance before asking patients to sign any paperwork.
To guarantee that insurers are on the same page as the organizations they partner with, a provider network should focus on establishing this level of transparency with their patients. For the best results, experts recommend this type of agreement be discussed early on in the partnership, such as in the network development phase.
Organizations can also share any protocols they have put in place for pricing transparency during provider contracting. If there is no outline to follow, organizations can collaborate to establish some alongside the insurer. Regardless of when it occurs, many insurers feel these discussions should take place to maximize satisfaction and health outcomes of all members.