The Out-of-Network Battle Heats Up

Jonathan Ishee, of counsel in the Vorys Houston office and a member of the health care group, co-authored an article for the ABA Health Law Section: ESource titled “The Out-of-Network Battle Heats Up.”   The article was about the provision of health care services by providers who are not participating in a health benefit plan’s network expanding as providers are either unable to become participating providers in a payor’s network or purposefully adopt an out-of-network strategy due to actual or perceived low reimbursement rates.

The article states:

“This move to provide healthcare services outside of a payor’s network and the resulting waiver of the patient’s portion of financial responsibility associated with receiving out-of-network services by the provider has heightened payment disputes between payors and providers.  This article examines recent legal action related to this dispute between providers and commercial payors.

The underlying issue in cases such as the ones discussed below center around coinsurance payments or the percentage of charges for the ‘covered expenses’ that an insured person is required to pay under the plan.  The payors’ position is that patients should not be enticed to seek treatment from out-of-network providers with a promise that their coinsurance will be waived or reduced, also known as a ‘discount program.’  The providers’ position is that offering discounts to the patients is not an unlawful practice and that nothing in the patients’ insurance plans allows the payors to pay less than the amount billed by the out-of-network provider.  These providers insist that such discount programs are appropriate and that payors should pay the full amounts charged. In response, payors have begun to take internal steps to avoid the “phantom charges” they claim are being billed by out-of-network providers.”

To read the entire article, visit the American Bar Association website.