Overcoming Out-of-Network Reimbursement Challenges: Assignment of Benefits, Improper Denials and Underpayments

Patients typically sign an assignment of benefits when they see a provider, assigning the patient's rights to recover benefits from the insurer. As a result, the provider is to be reimbursed directly for the healthcare services by the insurer. However, getting reimbursed is not as simple as executing an assignment of benefits. Insurers often challenge the validity and scope of these assignments.

As a result, OON healthcare providers face unique issues in obtaining proper payment from insurers when their patients have received OON services. It is important for the provider to have the patient properly assign his benefits as well as agree to take financial responsibility for the healthcare services received. Further, the provider should carefully bill patients, taking note that the patient, although OON, may still be a member of a plan with a repricing arrangement in which the provider also participates. The impact of state and federal surprise billing laws should also be considered.

When claims are denied or underpaid, healthcare providers need to understand the reason for the denial. Was there coverage for the patient? Is it a documentation issue? Did the claim fail to comply with payment policies and procedures? The provider must avail itself of any appeals available to it.

Listen as our authoritative panel of healthcare attorneys examines the challenges facing providers seeking reimbursement for OON services. The panel will offer guidance on properly documenting and billing for OON services, patient assignment, and the steps to take to overcome challenges with improper denials and underpayments.