Out-of-Network, But Not by Choice—How to Get Your OON Care Paid at the INN Rate: Part II

Congratulations! You survived your emergent illness and/or injury, and you’ve been discharged home to convalesce in peace. Not so fast, trooper. You may have gleaned some useful tips from my previous post on getting your OON emergency claims paid at the INN rate, but now you face the even bigger hurdle of getting your medically necessary, non-emergent OON care covered at the INN rate. I know you think that you won’t be using OON providers once you’re discharged because you plan to see your established INN physicians, and hopefully, this is the case. However, there are a few scenarios where access to outpatient INN care is incredibly burdensome and/or nonexistent.

For instance, if you happen to reside in a rural area where there are few healthcare providers (e.g., physicians, laboratories, physical therapists, home health agencies, durable medical equipment [DME], etc.), you could find yourself limited to OON providers. Moreover, your condition may require care from providers that typically aren’t contracted with any insurance companies. These providers are usually highly specialized physicians—hand and retinal surgeons and pediatric neurologists come to mind—or niche service providers, such as prosthetists, infusion companies, and respiratory therapists. These specialty providers are often OON because quite simply, they don’t have to be INN to garner their fair share of patients and healthcare dollars. Their skills are rare and in demand, and thus, they can be reasonably certain that when their services are needed, insurance companies will have no choice but to pay up and handsomely!

So, what recourse do you have if you find yourself facing one of the above scenarios, and the insurance company balks at paying for OON care at the INN rate? You can contact your insurance company’s preauthorization line and ask for a coverage GAP or network exception. You will need to be prepared to explain the extraordinary circumstances that leave you no option but to receive OON care (i.e., that you live in a rural or medically underserved area and/or there are no INN specialists available to treat your condition). The GAP exception request will be reviewed to confirm whether what you are contending is, in fact, true—that your care cannot be furnished by INN providers. If it is approved, you can expect that your OON care will be paid at the INN rate for at least a limited time period.

Insurance companies do not advertise the GAP exception process because they would love nothing more than for poor, ignorant you to believe you have to utilize your OON benefits, or worse, pay whatever the provider charges if you happen to have no OON benefits. The reality is that most companies have policies in place to address true “gaps” in their INN service areas. For example, the large insurer I worked for had the policy that if the nearest INN healthcare provider was located more than 60 miles or 30 minutes drive time from the member’s home address, we were obligated to honor GAP exceptions and pay OON providers at the INN rate. The same goes for treatment from providers like the aforementioned who are generally never INN.

Of course, this does not give you carte blanche to access services not explicitly authorized by the insurer. Just because you received the okay to have OON care at the INN rate from one provider does not mean the same goes for other services. Everything has to be reviewed individually on its own merit. Also, understand that your insurer will never agree to pay for OON charges at the INN rate indefinitely, so do not assume anything, and always request the authorization of services in writing. As always, you will need to remain vigilant in reviewing your EOBs to ensure your claims are being paid correctly going forward. Remember the electronic billing morass I discussed in the previous post? It will continue to be the bane of your existence.

I won’t lie to you. Negotiating the GAP exception process is a bitch, but the alternatives are to fork out your own big bucks (if you’re lucky enough to have discretionary funds) or forego care that could quite possibly save your limbs and life. Aren’t these reasons enough to summon your inner bitch and fight a system that is perfectly content with allowing you to deteriorate and die for lack of affordable treatment? Yeah, so you need one hand to steady your walker. There’s no reason you can’t raise the other and make a call, okay multiple, frustrating calls. You get my point. Stand up for what’s rightfully yours!