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The 2016-2017 plan year began on September 1, 2016, and with the new year there is a change in the way benefits are applied for certain out-of-network providers working in network hospitals. Affected out-of-network providers are those who provide emergency room, anesthesiology, pathology, and radiology services. Effective September 1, 2016, claims for these types of services, when received from an out-of-network provider in a network hospital, will be paid at the out-of-network benefit level consistent with how other out-of-network providers are paid under the UT SELECT Medical plan. These types of claims will no longer be paid as if they are from an in-network provider (with benefits paid based on 100% of billed charges).
Instead, out-of-network provider claims for hospital-based services received in network facilities will be processed based on the allowed amount that network providers have agreed to accept, which is the standard benefit for all other out-of-network providers. This means that out-of-network providers working in network facilities will no longer be reimbursed for the difference between what the provider bills (billed charges) and the lesser amount at which BCBSTX contracts with network providers for the service (allowed charges).
Why the Change?
Claims data was analyzed over a recent 12-month period for which all claims have been finalized. This analysis showed that from October 1, 2014 through September 30, 2015, about 66,000 UT SELECT members received hospital-based services from network providers resulting in approximately $37.3 million paid by the UT SELECT Medical plan. During the same time period, about 8,100 UT SELECT members received network hospital-based services from out-of-network providers who were paid a total of around $11.1 million. Based on this recent data, by changing the benefit to match the standard structure under which the UT SELECT plan normally pays out-of-network providers (based off of the network allowed amount rather than their higher billed amount), the UT SELECT Medical plan would save about $8.8 million dollars per year. Also, paying non-network providers their full billed amount makes it more difficult to establish network contracts, which drives up member and plan costs.
Members Need to Know
With this benefit change, UT SELECT members who receive hospital-based services from out-of-network providers may be responsible for paying the out-of-network provider for the additional billed amount above the network allowed amount. This balance will no longer paid by UT SELECT. If your out-of-network provider doesn’t write off the amount above the BCBSTX allowed amount, you may be balance billed for the additional amount, which can be substantial. This is why it’s very important to choose BCBSTX in-network providers when utilizing your UT SELECT benefits for medical services.
Managing your Benefits
Using BCBSTX network providers will help you better anticipate the charges associated with your treatment and ensure that you are protected from any balance billing. With network providers, you are also protected from higher expenses by your UT SELECT coinsurance and annual out-of-pocket maximums. This means that using network providers when you receive treatment results in substantial savings for both you and the UT SELECT Medical plan.
To assist you in planning for your treatment so you can be sure to use BCBSTX network providers, we’ve created a brief checklist for you to refer to when meeting with your provider.
