Repricing on Health Insurance Claims

We’ve all heard stories of the emergency call that cost $10,000 for a broken thumb, or the person who had to go bankrupt from the huge bill while using a network outside of their HMO. These stories have fueled debates about what to do with our Nation’s healthcare system. The truth is, these stories pop up more than most people realize, and many have a misconception about how it happened. That’s why it’s so important to have the right billing network to take advantage of the most affordable, predetermined pricing available.

Let’s look at a few scenarios where one person is stuck with a high medical bill and the other is spared. Suppose two people, one with adequate health insurance and the other without, enter the emergency room for the same injury. The emergency department will know right away that each patient will be billed differently. The person with the right network billing plan will be able to take advantage of a nationwide network that allows predetermined pricing for most medical conditions you can name. The other will be at the mercy of what the emergency department decides to charge. Depending on the medical condition, the difference between the amount paid can be tens of thousands of dollars. The problem is that in order to receive this preset billing, you must have access to the participating billing network.

When you take a closer look at how these billing networks work, it becomes clear where you might be exposed, especially on smaller networks. No one knows this better than the self-employed and those who do not have business insurance. When a person purchases health insurance on the exchange (, the only network option available in Texas is HMO or restricted networks. These networks are created for the insurance company and the healthcare institution to share the losses, while hoping to bring in large numbers of patients to balance the claims. Even this smaller type of HMO nets can have large holes in billing nets. For example, if someone has a surgery within the HMO network, they may still be in for an unpleasant surprise when the final bill arrives. While their surgeons are likely to be insured, both the anesthesiologist and surgical instruments rented for the surgery can fall off the billing HMO network and result in thousands of dollars being paid by the patient. You guessed it, not a warning, just a bill that health insurance won’t cover well after surgery.

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The only way to avoid a small HMO network pricing trap is to take advantage of much larger billing networks that allow you to avoid undiscovered pitfalls. These larger networks or providers may have hundreds of thousands of doctors and medical institutions participating from coast to coast. Many of these nationwide networks mandate that their preferred discount be their primary or leading method of billing, protecting the patient’s financial interests from any threat of overpricing. In fact, these preset pricing modules are so accurate that some insurance companies build their coverage to reflect preferred billing, thus limiting out-of-pocket expenses to thousands of dollars. Those who use this service can rest easy knowing that their interests will be protected going forward from the right billing network with unlimited nationwide networks.

While these billing network giants are difficult to understand in today’s ACA health insurance environment, they do exist across the country, including Texas. In fact, in the last few months alone, I’ve helped dozens and dozens of customers take advantage of these unlimited networks at much more reasonable prices than ACA policies. When choosing the right health insurance plan for your family, it’s important to consider network billing plans, especially for those who don’t qualify for the subsidy (federal income credit for the underprivileged). It is extremely important that you consult with a health insurance professional who has access to these unlimited billing networks to protect your financial interests.

About Lily Hammond

I have been working as an insurance consultant in my own insurance agency since 1998. Because I've been doing this for so long, I know every detail and I'm here to help you. You can find my e-mail address and work phone on the contact page.

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