By Martine G. Brousse (not AI!)
"The Medical Bill Whisperer"™
Patient Advocate, Certified Mediator
AdvimedPro
March 10, 2025
More and more patient must turn to Out Of Network (“OON”) providers for care – after a treating physician’s referral or due to lack of an In Network choice – and then must get reimbursed themselves from their insurance.
This indirect pathway too often causes delays, denials and issues. What are the 2 main problems and how to fix them? Let’s explore.
A. Problem # 1: Poor Medical Records
1. OON records too often lack clarity, accuracy, depth and even typed reporting, as these providers do not deal with insurances for pre-authorizations or requests for clinical documentation.
2. Because OON records are not expected to be “shared” with an insurance, the result can be poor notes, lacking legibility, even “barely there” notations.
3. Too often, the documented justification for or description of a rendered service is poor or lacking.
4. Smaller or individual practices may not use an Electronic Medical Record system at all, and write scribbles on a paper chart instead.
5. Smaller or individual practitioners may not have enough time (or staff) to write and keep detailed records, let alone manage external clinical documents.
6. This leads to insurances rejecting reimbursements due to non-compliance, lack of response or lack of medical necessity or justification. As the Medicare rule goes (widely used within the healthcare industry): “If it’s not written, it does not exist. If not in the records, it did not happen”
B. Problem # 2: Poor Billing records
1. Providers who do not directly bill insurance companies, do not receive Explanations of Benefits (“EOBs”), are unfamiliar with Billing and Payment processes, and are often responsible for denied, pended or un-processable claims
2. Smaller practices or individual practitioners may not use an Electronic Medical Record system at all, generating superbills or invoices on a Word document or through a simple but inadequate invoicing app such as QuickBooks.
3. Lack of a billing person, or one who is inexperienced often lead to limited knowledge of coding and billing protocols, coverage rules and insurance requirements for reimbursement of invoices.
4. The patient’s reimbursements will be delayed at best, denied otherwise, when invoices or superbills lack proper codes, info or required fields. “If it’s incorrect, invalid, incomplete or illegible, it can’t be processed and therefore paid” (healthcare logic)
C. Fix it!
1. Continuation Of Care authorization: if the provider recently terminated their contract with your plan, or is not In Network with your (new) current plan, you can apply for Continuation of Care until your ongoing treatment is over, or until your condition has stabilized enough to safely transfer your care. Such an authorization can ensure continued payment at the In Network rate without hassles about clinical justification.
2. Single case agreement: If the OON provider agrees, the insurance can pay them directly at the higher In Network rate and you get a discount. Yes, the provider would get paid less than OON, but they would avoid clinical necessity inquiries or demands for records. And the agreement would only apply to your services.
3. In-for-out authorization: if no In Network provider can render the service, your insurance may be forced to cover OON services at the In Network rate. You would have to show that you tried finding an equivalent, available, trained, experienced In Network clinician but failed.
4. Insist on proper Medical Records keeping, especially if you see hand-written, one-liners, “barely there” reports or notes. Ask if a specific day’s report can include info your insurance requests (family and personal history, vital signs, medication list, allergies, list of diagnoses, conclusion, treatment plan etc).
5. Every visit/session/service should also include: total time spent with patient or reviewing external records, reason for service, level of complexity of decision, detailed list of services rendered, supplies used, documents reviewed, referrals issued, prescriptions prescribed, tests or labs ordered, treatment plan discussed, and provider’s signature.
6. Insist on proper Billing records and necessary info:
· Tax ID# and NPI # of billing entity
· NPI #, credentials and contact info of treating physician
· Date of service, procedure code(s), diagnosis code(s), place of service
· Signature of treating clinician
· Price per unit and overall
· Type of service (outpatient vs inpatient)
· Specific circumstance(s) etc
7. Ask for specific assistance
· How can you help with this ?
· How soon can you update/correct/initiate/respond/provide…
8. Don’t take “no” for an answer
· Or “this is how we always do it”
· Or “you deal with your insurance”
· Or “we don’t have to”
· Or We don’t know how”
· You pay 100% of the bill and are entitled to everything this office/provider can give you in order for you to get reimbursed as much as possible!
9. Keep track and follow up
· of any insurance request, to you or the provider
· of any EOB that is not “paid”
· if 30 days have passed since you uploaded an invoice or superbill for reimbursement
· Don’t merely resubmit a “pending” claim or missing invoice. It will likely result in a “duplicate” denial, causing more delays while timeliness deadlines may lower chances of success. A call to the insurance can help determine what the next best step is to push your claim forward, and a check in the mail!
Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.
(424) 999 4705 - F (424) 226 1330
@martine brousse 2025 @ the medical bill whisperer 2025™
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