Participant Out Of Pocket Cost Issues When Using OON Services
There are two components to the price a Participant pays when using an In-Network (INN) provider. The PWGA has already negotiated a fair market price for INN services, and covers 85% of that amount, with a maximum annual Participant out of pocket exposure of $1,500. When a Participant uses an Out-of-Network provider there are limited price protections. The provider is not contracted within the Anthem network, and they can charge whatever they want, even though in almost all cases there is a reasonable and customary amount for such services, and the Participant will be responsible for the provider’s terms if the Participant signs off on these costs.
The provider bills you for the difference between what the PWGA allows (the reasonable and customary amount) and their price. What this means in practice is that if an INN provider charges $1,000 for a service that has a reasonable and customary price of $600, the PWGA would pay 85% of the $600 price, $510, and the Participant would be responsible for $90 (unless the INN annual out of pocket maximum of $1,500 has already been reached).
If an Out-of-Network (OON) provider charges $2,000 for the same service, then the PWGA would pay 60% of the reasonable and customary price: $600. The OON provider would bill $1,400 and the Participant would be liable for this amount unless the annual out of pocket maximum of $20,000 had been reached. This is known as “balance billing”. The Participant out of pocket exposure to significant additional personal costs when utilizing OON provider services is critical to understand.
IMPORTANT: If you are using an OON provider, check with the PWGA to make sure the procedure in question is a covered service, and understand your personal cost exposure vs. what that exposure would be if you chose an INN provider, before you sign anything. You do not want to be stuck paying for 100% of a bill because it is not a covered service, or is a service where your OON provider overcharges as compared to the reasonable and customary amount for the service in question. Additionally, the PWGA may be able to negotiate with the provider to achieve a lower price for the service for you, but we can only do so if you do not sign off and execute the service in advance of reaching out to us.
Quality Of Services
Participants may have a longstanding relationship with an OON provider and there may be a basis of trust. Price is not the primary consideration in such a situation. Nevertheless, it is worth noting that all the PWGA INN providers go through an annual credentialing process that is overseen by the Office of Inspector General. Such providers are also under contract within the Anthem network to charge reasonable and customary rates for their services. Some OON providers end up on a preclusion list which may prevent them from providing certain kinds of services – or any services at all. No one wants to think that a provider they have used for many years is less than stellar at their profession, charges fees that are exorbitant when compared to reasonable and customary rates, or treats their patients with less than highest quality of care. The PWGA’s credentialing procedures ensure this is so. INN providers are credentialed yearly – or if there is an incident, immediately thereafter. Thus, when using an INN provider, a Participant can be certain they are getting quality service that meets the highest standards. With an OON provider, there is no way to know about their professional capabilities, or any other issues which may affect your treatment or cost exposure.
Another consideration is paperwork. When you are getting medical services from an INN practice, the provider does the paperwork for you. The PWGA pays the providers directly. You are only responsible for your portion of any remaining balance. If you are receiving OON services, if your provider doesn’t file a claim for you then you’ll have to file a claim when you receive the bill. You’ll have to go the PWGA website to get the proper form(s). And you will have no control over the cost.
Recourse If Something Goes Wrong When Utilizing OON Providers
Even with the most trusted OON providers there are a few precautions a Participant should take:
- Always check with the PWGA before signing an agreement for an OON service or procedure. Make certain that the service or procedure in question is indeed a Plan covered service or procedure.
- Check with the PWGA to see how much of the cost of a given service or procedure is covered by the PWGA (if any). An OON provider can charge whatever they want, whereas INN providers have agreed to compensation rate levels. If the pricing is out of line with industry norms, you want to know that before you sign an agreement to be responsible for the cost. If the service is not covered at all, you want to know that before you obligate yourself to paying potentially many thousands of dollars.
If there is a problem with a Provider’s OON billing, the PWGA may be able to help. If you feel you have been overcharged, contact the PWGA. We will do whatever we can to assist, but keep in mind, the PWGA does not have the same (and may not have any) leverage as they would with an INN provider. With an INN provider, the PWGA can seek reimbursement if there is an overcharge. An INN provider will never provide a non-covered service, so you can be assured you won’t face any unpleasant billing surprises.
The Bottom Line
You are always going to be better protected and paying a lower price when dealing with an INN provider. You will always have much better recourse if something goes wrong with an INN provider. If you nevertheless opt to seek services from an OON provider, make certain in advance that your treatment is covered, and that the costs for that treatment are in line with industry norms. If you’re going to an OON provider, a little proactive investigation can save you from some unpleasant surprises.