Out-Of-Network Balances- Who Gets the Bill?

Published on July 16, 2021

When anesthesia providers have a contract with an insurance, the insurance has a set rate that they pay per unit for each claim. This is considered processing “in-network”. However, when providers are not contracted with an insurance, but they bill a claim to that insurance, the claim is processed as “out-of-network”. This means that the insurance will pay up to what they deem “usual and customary” for the procedure or services provided. This can leave the provider receiving little to no payment on the claim, and they must then decide to either balance bill the patient or take the hit and adjust off the remaining balance. With many states moving to enforce a No Balance Bill Law, balance billing the patient may not be a choice much longer, but there is another step to take before taking the adjustment for the remaining balance.

When patients have anesthesia services, or any other ancillary services, provided at hospitals, they do not typically have a choice as to which provider performs those services. While the facility itself may be in-network with the patient’s insurance, the patient could unknowingly have ancillary services rendered by a provider who is not in-network with their insurance. Since neither the patient nor provider are aware of this before the services are rendered, and the provider is not contracted with the patient’s insurance, the patient could be left with a large, unexpected bill.

When this happens, most insurances understand that the patient did not have a choice in the ancillary provider and may be willing to process the claim at a higher, in-network rate as long as the facility is in-network with the provider. The provision on the insurance policies that will allow the insurance to reprocess these claims is often times referred to as a RAPS or RAPLES provision. This stands for Radiology, Anesthesiology, Pathology, Labs, and Emergency Services. If the insurance has this provision in their policy, they should check to see if the facility is in-network and, if so, send your claim back to be reprocessed simply by calling them and asking.

The name of this provision can be different for each insurance, and not all insurances will have this provision, but this is something worth asking for before taking the adjustment or balance billing the patient. In some instances, the insurance may require the patient to call and request the reprocessing of the claim, but as long as it is requested the insurance will typically come back and make additional payment. So, before balance billing the patient or adjusting off the balance, call the insurance and see if the claim can be reprocessed under RAPS!

Miranda Long

AR Representative