The healthcare market is constantly changing. Before, patients could visit any doctor, hospital of healthcare facility without worrying if their insurance would cover the expenses. But that is all on the past. Now, most insurance plans restrict patients as to what medical providers they can see, by refusing to pay for those services and care. It forces patients to conform to a limited number of healthcare providers that are inside their insurance network. But if patients visit or receive care, knowingly or not, from a provider not covered by their insurance, they are going out-of-network (OON).

What exactly is out-of-network

OON refers to physicians, hospitals or any other healthcare providers who are not inside a patient’s insurer’s provider network. OON is becoming more common since the rise of narrow networks, cheap premium healthcare plans that limit the patient to receive care from a handful of in-network health care providers and hospitals. Around 18 billion out-of-network health claims were made between 2013-2014, according to a study by America’s Health Insurance Plan (AHIP). Since narrow networks mean fewer providers are in a patients network, it will continue to result in more out-of-network care.

 

table of the most common out-of-network medical procedures and charges based on procedures, annual event count and average claim cost
Most Common OON Medical Charges

 

Even when a provider or hospital is in-network for a given plan, one or more of the doctors whom an insured patient sees while there, may be out of their network. Patients with comprehensive health insurance are getting hit with unforeseen and often substantial out-of-network bills. 18% of inpatient admissions result in out-of-network charges for the patients.
The charges typically arise when a patient goes to an in-network hospital but at some point, most times unknowingly, receives care from an out-of-network medical professional. For example, patients who needed anesthesia or pathology service were more likely to receive out-of-network bills, which may not be covered by their insurance. Or patients that needed mental health and substance abuse treatments were also more likely to be billed by out-of-network providers.

 

Submitting OON Medical Claims

Depending on an individual’s health insurance plan, expenses incurred for services provided by out-of-plan health professionals may not be covered. Or they may partially covered by an individual’s insurance company. The patient is forced to pay for the services out-of-pocket, with their own money. Later submit that claim to their insurance provider for reimbursement.

Making these medical insurance claims is an arduous process, it’s extremely time consuming and prone to errors. Patients are forced to fill out paper forms, and send them to their health care providers or do them electronically. Then, they must wait for a response and later, if approved, receive a reimbursement.  If denied, they must through the process again.  They could also negotiate those bills with the hospital to bring down the costs, but this hardly happens. Patients sometimes even hire medical billing advocates to handle their claims, however, they must pay a fee for their services.

Other patients opt to use mobile applications to eliminate the stress of submitting the forms. They use apps such as Claimeye a mobile app that facilitates and expedites the process of submitting OON medical claims. Claimeye eliminates the hassle of filling out a form and mailing it to the insurance provider, to wait for a response and reimbursement. With the app, the patient simply takes a picture of the insurance card and the receipt. Claimeye will handle the rest.

 

Can patients choose out-of-network care?

The most attractive reason for patients to opt for out-of-network is the fact they can choose any provider they wish. Patients have the freedom to decide which doctor, hospital, health facility or lab they choose, if they are willing to pay.  As a result, there has been a rise in tools that aid patients in the reimbursement process of OON claims, such is the case of Claimeye. 

Patients don’t have to worry anymore about going out of their network, or even handling the process of submitting their out-of-network medical claims.

Try Claimeye!

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