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Paying out-network providers at in-network levels.


Guest Damien
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Guest Damien

I am casting about for general input from TPA's and other self-funded players. Has anyone had to address the question of out-of-network providers rendering services at an in-network facility? This hardly ever seems to be fully addressed in the plan documents I read, amd I was wondering how other people were handling it.

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Guest taylorjeff

I've seen it handled both ways.

If the carrier / TPA takes the hard and fast approach, non-network providers are paid at the non-network level.

The more liberal approach takes into account that often the hospital and admitting doctor are network providers but sometimes the hospital based docs (anesthesiologists, radiologists, pathologists)are not under contract. The administrator usually has to adjust the claim after hearing from the claiment. The payment is made at the network level. The problem you run into is that even when the payment is paid at the higher network level it is based on the PPO schedule and is considerably less than U&C. Since the other providers have not signed a contract, they can balance bill the patient.

Also, if emergency (at least in Illinois), the PPO / POS plan is supposed to pay the network level benefit regardless of facility contract.

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It's called a RAPS provision - for "radiologists, anesthesiologists and pathologists." The idea is that patients in a hospital or other treatment facility frequently have no choice about these particular specialists; you get whoever's available or on call at a given time.

The RAPS provision allows for these types of providers to be paid at network coinsurance (subject to U/C), if treatment is rendered in a network facility.

I think it's actually a pretty common provision in PPO plans.

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