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Comment - An end in sight to Out of Network?

August 16, 2011

Crain's reported today on Empire's new urgicare app, identifying same as "a major push to get patients who don't really need emergency-room care to use urgent care centers instead." The availability of access to information steering patients away from emergency care is one of the more innocuous tools I have seen Empire utilizing. The more hazardous to my clients has Empire's placement of providers on pre-payment review, a horrendous process where every record is required to be sent prior to reimbursement, just because the provider is out-of-network and rendering services at a hospital. Empire's position is clear - it no longer wishes to pay for hospital services that are not absolutely medically necessary - and even those may be denied at first or wrenches thrown in the payment chain.

Of course sending a patient to an urgi-center as opposed to a hospital is not requesting the patient be seen for free. Empire's presumption must be that the urgi-center will be paid at lower rates than the neighboring hospital. This policy creates a number of issues for practitioners - the first being that out of network benefits many practitioners live off of may become fewer and further between. Hospitals as well may feel the effects of this policy - as insured patients flock to urgi-centers, hospitals may be left with mainly uninsured patients.

If other insurers follow suit, a deeper wedge may be placed between participating v. fee for service, as the out-of-network option is taken out of the picture. It goes without saying that patients are not yet aware that even though they pay for out of network benefits, they will most likely not be able to avail themselves of out of network. One of the main reasons this is the case is because practitioners are not meeting their balance billing requirements.

 

Copyright © 2011 by Kirschenbaum & Kirschenbaum, P.C.

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