SPA thought the payer lists would help because patients often call ahead to
find out if the practice takes their plan. But when they arrive and show their insurance card, “that’s when the trouble starts,” Dr. Abel said. One SPA physician recently treated a new patient whose ID card listed on the
front an EPO network the doctor knew he participated in, but the plan denied payment for the claim saying he was out of network. The practice and TMA Payment Advocacy staff researched the issue and found the doctor listed as in network in the plan’s directories and online eligibility verification portal. After much digging, TMA discovered the back of the card listed an acronym
for a completely different network that restricted the patient to a specific ac- countable care organization (ACO) for care. None of that information came up in TMA’s research, and the payer’s own web-based guidelines to help physician practices interpret patient insurance cards say any ACO information should be listed on the front. The plan insists on denying payment because the physician is not in the ACO network, and TMA is still working to resolve the claim. (See “TMA Resources,” page 30.) “You’re not just getting the wrong information from the portal; you’re get-
ting wrong information from humans, from the card, everywhere,” Dr. Abel said. “Doctors can’t work for free. If I’m being told by the insurance company that I’m in network, and it turns out I’m not, why should I take the financial hit for that?” TMA also received reports from unwitting out-of-network physicians to
whom hospitals refer patients because they are the only specialists in the area. That leaves the physician and the patient with unpaid and unwanted bills.
“Nobody wants surprise bills. But the real problem is not balance billing. The real problem is narrow networks.”
Are out-of-network health plan payments less than half of your charge for the service?
All
of the time
11%
Never 5%
Rarely 11%
Often 36%
Sometimes 37%
May 2016 TEXAS MEDICINE 33
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