Out-of-Network Claims Mediation

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One of the services you may offer as a life and health agent is assisting your clients with the claims process. They may call you after they receive that rather large emergency room bill and question why one of the doctors they saw was out-of-network when the hospital was in-network. You can offer the typical advice, such as matching up the explanation of benefits with the itemized bill, but did you know that you can suggest mediation for certain out-of-network claims?

Thanks to HB 2256 passed in the 81st Regular Texas legislative session, you may be able to offer your clients that option; however, your clients’ claims must meet some mediation eligibility requirements, including:

  • The claim was filed after June 19, 2009 for a medical service or supply provided by an out-of-network hospital-based physician in a hospital that is in their PPO.
  • The claim is more than $1,000 (excludes copayments, deductibles, coinsurance).
  • The hospital-based physician did not provide complete disclosure before providing the service or treatment.

Going through mediation doesn’t mean your client doesn’t have to pay the claim, rather it’s a way to open dialog with your client, the physician and carrier concerning what monies are owed. The process of mediation can take some time but the physician can’t attempt to collect any payment until the mediation is resolved or withdrawn. Full details on how the mediation process works; including helpful forms, timetables, rules and a consumer guide to health care billing, are available on the Texas Department of Insurance website.

Misty Baker, SGS
Director of Life & Health Insurance Information
Independent Insurance Agents of Texas
1115 San Jacinto Blvd, Ste 100
Austin TX 78701
800-880-7428 ext 132
mbake@iiat.org

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