Effective June 1, 2015 American is changing its out-of-network reimbursement under the Standard, Value and Core medical options to limit reimbursement for out-of-network services to 140 percent of published rates allowed for Medicare.
This means that your health plan may reimburse the out-of-network provider less than the fees they charge. Although you may continue to receive care from out-of-network providers, the lower out-of-network reimbursement level will apply. You should also be aware that the provider may bill you the balance of their fees not covered by your plan. You may be responsible for this amount (plus any out-of-network deductible, coinsurance or copay). This amount does not count towards your out-of-pocket maximum.
Background
With health care costs at the forefront of everyone’s minds, it is important to be an informed consumer and always go to providers (doctors, hospitals, clinics, labs or imaging centers) in your health plan’s network. In-network providers are contractually obligated to accept pre-negotiated fees for their services which means that you are receiving the best care at the lowest cost. When you visit an out-of-network provider, a provider can bill any amount for their services and you may pay significantly more out of your pocket for care With more than 90 percent of all hospitals and 80 percent of all doctors in the United States contracting with BCBS and/or UHC, in-network options are readily available.
Cost of out-of-network providers
When looking for health care, it is important to specifically ask the doctor’s office, hospital or facility if they are in your network. If you ask if they simply “take Blue Cross Blue Shield” (or United Healthcare), they may accept your insurance but are not necessarily an in-network provider. Here’s a prime example that highlights the importance of asking the right questions.
Susan’s doctor advises her to get an MRI to help treat her knee problem. The doctor tells Susan there’s a convenient imaging center across the hall, so Susan gets her MRI done there. Susan later learns the imaging center has charged her $30,000 for the MRI and didn’t realize she went to an imaging center that is out-of-network. Susan also learns she may be liable for the extra charges beyond what her health plan will pay.
This situation is happening to more people every day, including American’s employees. Some out-of-network providers charge inordinate fees and unfortunately, employees and the company must pay these costs when high quality and less expensive providers are available. A new report by Dyckman & Associates shows that some physicians who choose not to participate in health insurance networks are charging patients fees that are 10 times – and in some cases, nearly 100 times – Medicare reimbursement for the same service in the same geographic area. Below are examples of some of their findings in the 30 largest states.
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