Re-pricing of health insurance claims

We’ve all heard the stories of the emergency room claim costing $10,000 for a broken thumb, or the person who had to bankrupt the huge bill while using a network outside the HMO. These stories have been fuel for arguments about what to do with our nation’s healthcare system. The truth is, these stories happen more than most people realize, and many have misconceptions about how this happened. This is why it is so important to have the right billing network in order to take advantage of the best pre-determined rates available.

Let’s look at two scenarios where one is stuck with an exorbitant medical bill and the other is protected. Suppose two people enter the emergency room with the same injury, one with adequate health insurance and the other without any. The emergency room will know right away that each patient will be billed differently. A person with the right network billing plan will be able to take advantage of a nationwide network, which allows for preset pricing for most medical conditions you can name. The other will be at the mercy of what the emergency room decides to charge. Depending on the medical condition, the difference between what is paid can run into the tens of thousands of dollars. The catch is, in order to receive these predefined billings, you must have access to a participating billing network.

When you take a closer look at how these billing networks operate, it becomes clear where you might be exposed, especially on smaller networks. No one knows this better than the self-employed and those who don’t get insurance through work. When an individual buys health insurance on a stock exchange (Healthcare.gov), the only network options available in Texas are HMO, or restricted networking. These networks were formed for the insurance company and the medical establishment to share the losses, with the hope of bringing in an excess volume of patients to compensate for the claims. Even this smaller type of HMO network can have major holes in their billing networks. For example, if an individual has had surgery within their HMO network, they may still have an unpleasant surprise when the final bill comes. Although the surgeon is likely to be covered, the anesthesiologist and surgical instruments rented for the surgery may fall out of the HMO’s billing net, causing thousands of dollars to be paid by the patient. You guessed it, not a word of warning, just a bill that health insurance won’t cover well after surgery.

The only way to avoid the small network HMO pricing trap is to take advantage of the much larger billing networks, which allow you to avoid the pitfalls that are not exposed. These large networks, or providers, can have hundreds of thousands of participating physicians and medical institutions from coast to coast. Many of these nationwide networks make it mandatory for their preferred discount to be the primary or most advantageous method of billing, protecting the patient’s financial interests from any threat of overpricing. In fact, some insurance companies’ preset pricing units are too accurate to reflect their coverage to reflect preferred billing, thus limiting outgoing expenses by thousands of dollars. Those who use this service can rest easy knowing that their interests will be protected moving forward from the right billing network with nationwide unrestricted networks.

Although these billing network giants are elusive in today’s ACA health insurance environment, they are found all over the country, including Texas. In fact, I’ve helped dozens and dozens of clients take advantage of these unfettered networks over the past few months alone, at much more reasonable premiums than ACA policies. It’s important to consider network billing plans when choosing the right health insurance plan for your family, especially for those who don’t qualify for a subsidy (the federal income credit given to those with limited financial resources). It is very important to speak to a health insurance professional who has access to these unfettered billing networks, in order to protect your financial interests.