The Shifting Out-of-Network Reimbursement Playing Field

Recent lawsuits and industry changes have dramatically altered the out-of-network reimbursement ‘playing field.’ Additionally, pending litigation is aimed at further redefining certain aspects of the body of law that governs out-of-network reimbursement.

It’s important that healthcare providers understand the new ‘rules of the game.’ In an effort to shed light on these changes, upcoming blogs will address the following key aspects of these important developments:

  • Basics of out-of-network reimbursement
  • Key elements of usual, customary and reasonable (UCR) computation
  • History of the Ingenix-related UCR litigation
  • The emergence of FAIR as a replacement to Ingenix for UCR benchmarking
  • Recent litigation against out-of-network providers who allegedly charge unreasonably high fees
  • Pending litigation against out-of-network providers who regularly waive patient responsibility amounts
  • Pending litigation involving in-network providers who refer subscribers to out-of-network providers

Stay tuned.

The article, Shifting Out-of-Network Reimbursement Playing Field; by Stephen Snyder is published in Payors, Plans and Managed Care newsletter, PPMC. The PPMC addresses all legal issues concerning health plans and insurers. The article is highly appreciated by PPMC as it covers how dramatically lawsuits and industry changes altered the out-of-network reimbursement ‘paying field’. To view the complete article, please follow the link below.

AHLA PPMC April 2012 Newlsetter