Empire BCBS is a leading insurance company and it has multiple plans as per the needs of its patients. One of its plan is called EPO INN COSTSHARE IN PRIORITY. As the name suggests that this is an EPO based plan. Before diving deep into the discussion, let’s learn what EPO plans are.
“An EPO, or Exclusive Provider Organization plan, is a type of insurance plan in which patient can enjoy the flexibility of visiting any provider without needing to have prior approval or referral from another provider. So in simple words patient is not required to have any PCP locked in plan but that PCP also needs to be in network with patient’s plan.”
So based on above definition, if you someday, as a provider, see a patient who has such a plan and he gets some very expensive treatment from you in which you already are a specialist. Of course once a patient steps in, you might not be able to say NO to him. Now you treat him/her and done. You send the bill to your (other regular) billing company which as is sends the bill to insurance. But surprisingly insurance denies the claim stating that member has EPO plan and you, as a provider, are not in his network and hence no payment will be made. Your ordinary billing company sends the bill to patient but patient denies paying anything.
Above scenario can very much happen with specialists like therapists and skin specialists. Patient needed a laser treatment and you treated him/her but without taking a look into her/his plan. Now patient’s need has been met and it is less likely he/she might ever return.
Now your time and money both have been wasted. Your patient is also never going to come back to you because he/she wants to avoid making the payment to you.
If you use our billing services, we make sure that you are enrolled in all plans as per your community right at the time of singing up. Our professional team also recommends you what best suits you but in such a situation, we enroll you into that plan so that insurance does make the payment.
Is it as simple as that? No there are many leaps and bounds before deciding what the right way of recovering the payment is. We could send the reminders to the patients but why would patient come back for a treatment that he/she is planning to discontinue.