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procedure's real cost. Mr. Manigan says out-of-network facilities should
create a "consistent and compassionate" policy for collecting patient pay-
ments that doesn't involve "routinely waiving co-pays or deductibles."
Share of controversy
Out-of-network billing has drawn its share of controversy. In New
Jersey, for example, reports surfaced of physicians whose practices
were in-network allegedly "cherry-picking" patients to refer to the out-
of-network ASCs that they partially owned. For physicians in this situa-
tion, Mr. Manigan says it's important to be "transparent" and open about
the relationship with patients to avoid conflicts of interest.
Mr. Manigan says there are also a select few who have charged
excessive fees that have drawn attention to out-of-network billing.
These high fees routinely show up in news reports — like the $59,000
ultrasound charge and the $56,000 bedside consultation. He says that
New Jersey and several other states have created laws to protect
patients from huge bills when they visit an ER or hospital that's in-net-
work, but end up being seen by an out-of-network provider. However,
Mr. Manigan notes, while there have been some failed legislative
efforts in New Jersey to limit out-of-network charges for ASCs, insur-
ance companies can protect themselves by capping the amount of
out-of-network coverage.
"Every once in a while you read that some ASC submitted an outra-
geous charge," says Mr. Manigan. "However, in most jurisdictions, the
insurance carriers are free to design the benefits however they want to
design them. The carriers can protect themselves."
Mr. Manigan says insurers are trying to restrain the out-of-network
business by capping reimbursements and discouraging patients with
higher co-pays and deductibles.
C O D I N G & B I L L I N G
