YOUR CLIENTS’ PATIENTS STAY HEALTHY WITH CHECK-UPS... SO CAN THEIR PRACTICES! Published with permission of the American Medical Association (AMA) A new “Prescription for a healthier practice” check-up series from the AMA can help your clients’ practices stay healthy. The monthly check-ups help practices examine the health of their everyday administrative processes and provide related resources in areas that include practice automation, fair contracting, ensuring accurate payment, physician efficiencies, and clinical quality issues. Help your clients perform their own check-up in this area, and visit www.ama-assn.org/go/out-of-network to access additional resources. also, sign up for ama Practice management alerts at www.ama-assn.org/go/pmalerts to stay up to date with new check-ups in the series. Holding Health Insurers Accountable for Out-of-Network Services the healthcare industry is one of the only industries in which over 80 percent of the revenue for services comes from parties other than the consumers themselves. typically, the majority of physicians’ revenue is derived from health insurers or other thirdparty payors. therefore, physicians need to hold health insurers accountable to their agreements and/or payment responsibilities. this need to hold health insurers accountable is applicable even to physicians who are not contracted with particular health insurers. out-of-network physicians should protect themselves and their patients from unfair payment reductions. the first step to ensure fair physician payments is to make sure that your clients have up-to-date, defensible fee schedules. the fee schedules should appropriately represent the value of the physician’s services and be based on sound econometric (i.e., cost) and analytical processes. Physicians, like other professionals, have the right (and responsibility) to set their own fees based on their training, qualifications, length of time in practice, reputation, skills, practice expenses, amount of charity care, geographic area, and other relevant factors. Physician practice viability does not stop with the development of a sound physician fee schedule. Physicians should also know and understand their state laws regarding health insurers and other payors’ obligations to appropriately pay non-contracted (i.e., out-of-network) physicians. usually, when the physician does not have an agreement with the health insurer, the patient is responsible for the physician’s full, billed charge. in some cases, the health insurer will pay the physician directly. When a non-contracted physician receives a payment from a health insurer that appears unreasonable, the ama recommends that the physician request the calculation of the health insurer’s payment rate. in most states, a physician who deems the health insurer’s payment rate inappropriate after reviewing the calculation can submit a request for his or her full, billed charges or submit a counteroffer (often made contingent on timely payment) that he or she deems appropriate to the health insurer. there are three reasons why a third-party payor may directly pay a physician who is considered out of the health insurer’s network. the third-party payor may: 1. recognize the patient’s assignment of benefits to the physician (access a sample assignment of benefits at www.amaassn. org/go/out-of-network); 2. pay the physician by mistake, when it intends to pay the patient; or 3. adhere to federal or state law (e.g., emtala requires AMA Practice Management Center Resource Tip + for more information regarding physician fee schedules, visit www.ama-assn.org/go/dfstoolkit to access the defensible fee schedule toolkit, which includes the financial impact Worksheet tool (for ama members) and the resource, “fee schedule analysis: using practice costs as a guide” (available to all). 28 hbma billing • may. june.2013
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