Review of health insurance claims

We’ve all heard the stories about the emergency room claim costing $10,000 for a broken thumb, or the person filing for bankruptcy from the huge bill while using a network outside of his HMO. These stories have fueled arguments about what should be done with our nation’s health care system. The truth is, these stories are more common than most people realize, and many have misconceptions about how this happens. That’s why it’s critical to have the right billing network in place to take advantage of the most favorable pre-determined pricing available.

Let’s look at a few scenarios where one person is stuck with a high medical bill and the other is protected. Suppose two people walk into an emergency room for the same injury, one has adequate health insurance and the other has none. The emergency room will immediately know that each patient will be billed differently. The person with the right network billing plan can take advantage of a nationwide network, allowing for pre-determined pricing for just about any medical condition you can name. The other will be at the mercy of what the emergency room charges. Depending on the medical condition, the difference between what is paid out can be as much as tens of thousands of dollars. The catch is, in order to receive this predetermined 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 are not offered insurance through work. When a person purchases health insurance on the exchange (, the only network options available in Texas are HMO or restricted networks. These networks have been formed for the insurance company and medical institution to share losses while hoping to bring in too many patients to offset the claims. Even this smaller type of HMO networks can have large holes in their billing networks. For example, if a person has surgery within their HMO network, they may still be in for an unpleasant surprise when the final bill comes. While their surgeon will likely be covered, both the anesthesiologist and the surgical instruments rented for the surgery may fall outside of HMO’s billing network, forcing the patient to pay thousands of dollars. You guessed it, no word of warning, just a bill that health insurance doesn’t cover properly after surgery.

The only way to avoid a minor pitfall of HMO network pricing is to leverage much larger billing networks so you can avoid the pitfalls uncovered. Hundreds of thousands of doctors and medical institutions from coast to coast can participate in these larger networks, or providers. Many of these nationwide networks mandate that their preferred discount be the primary, or front-runner, billing method, protecting the patient’s financial interests from any threat of overpriced pricing. In fact, these pre-determined pricing modules are so accurate that some insurance companies adjust their coverage to suit billing requirements, cutting out-of-pocket costs by thousands of dollars. Those who use this service can rest easy knowing that their interests are protected from the right billing network with unlimited nationwide networks.

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While these billing network behemoths are elusive in today’s ACA health insurance environment, they exist across the country, including Texas. In fact, in the past few months alone, I’ve helped dozens and dozens of customers take advantage of these unlimited networks, at much more reasonable premiums than ACA policies. It is important to consider network billing plans when choosing the right health insurance plan for your family, especially for those who are not eligible for a subsidy (federal income credit given to those with limited financial resources). It is extremely important to talk to a health care provider that has access to these unrestricted billing networks, to protect your financial interests.