Frequently insurance companies are contacted after a claim has been processed by a consumer who feels their benefits were improperly paid when they receive Out-of-Network benefits for the diagnostic portion of their visit. This notion of an insurance company paying the higher level of benefits comes from the fact the consumer feels helpless to pick physicians that they do not have direct contact with. In the case of lab work, the patient is only able to see the blood get drawn, but normally does not take in to account the lab technician that actually performs the test.
In certain cases the current health plans do implement a way of paying the higher level of benefits to a doctor that the member did not directly see in order to cover unneeded patient responsibility. This verbiage is included into a policy to help keep the rising cost of patient responsibility to member at a minimum and make the process of seeing a medical practitioner much easier.
This clause does work like a well-oiled machine when it is on a policy, but you must verify the details before assuming that this is on your policy. First, not all plans are written with this clause written in them. So it is possible that your employer has opted out of this option. Next, the clause only is valid on claim done on ER, OP surgery, and IP hospital stays. RAPL would not apply to any other services. Another downfall is that it is not readily available for you to see through normal means of checking your policy. This information can only be obtained by calling to a representative and asking them specifically what would happen if a scenario such as this would occur.
In the circumstance where your policy does not have the outpatient diagnostic rider on it you would then have to verify that all practicing medical personnel were part of your insurance network. Otherwise, you can/would be subject lower if any benefits for the services. Which when taking into account things like reasonable and customary or maximum non-network reimbursement can leave a member with thousands or even tens of thousands of dollars of out-of-pocket expense.
To guarantee the best level of benefits you must be educated on your policy. Knowledge will guarantee that you don’t spend more money than is due for your benefits. Yes, the amount of work increases for you when must do to check all providers that are involved in your care. It is best to use the resources that are now provider by your insurance company to help in this lengthy process. Be involved with your health care by using website portals, call centers, and etc… to be one step ahead of your care. Putting this knowledge into action with certainly save you more time and money than you had ever thought possible.
Last note: This subject is also very intertwined in what type of funding is elected for by the plan. Fully insured plans that do not carry Out-of-Network benefits will most likely receive this clause as it is mandated by regulations.