Out of Network? No Problem. Reimbursify to the Rescue.

One gigantic headache that both patients and health care providers face is getting reimbursed for out of network claims. If a particular doctor or health care professional (physical therapist, psychologist, etc.) does not have a contract with an insurance company, then the care they provide is considered out of network. This doesn't mean that the visit or therapy won't be paid for but just that the claims process will not be streamlined for the patient. Essentially, it is left to the patient, or helpful practitioners, to fill out the paperwork and submit to the insurance company for reimbursement.

Why are People Out of Network?

Getting your care from someone out of network doesn't necessarily mean that you are going to someone who is on the fringe or provides unusual care. It simply means that they do not have a specific contract with your insurance carrier. Sometimes this is because your carrier has a very small market share so it isn't worth the trouble to negotiate an agreement. Other times, it is simply that the carrier doesn't bother contracting with certain types of specialists because there are too many (like physical therapists or laboratories) in a certain area and it is simpler to just have patients or those providers file claims. Being out of network is very common but can present problems when it comes to getting reimbursed for your health care expenses.

What is Filing an Out of Network Claim?

Filing a claim is similar to asking for reimbursement for some expenses you incurred on a business trip. Usually, you submit receipts from restaurants, airlines, and hotels when you return from a work trip. You spend your own money up front and then later receive compensation from your employer after they process the receipts. Out of network billing works in a similar fashion except it requires more details and specialized forms to complete. Each form requires the usual personal information (name, birth date, etc.), a diagnosis code or ICD-10, and a procedural code or CPT.

What Is so Hard About Filing Claims?

The difficulty in filing claims is exactly as you'd expect with any bureaucratic process. It is sometimes slow but can easily be rejected if something is filled out incorrectly. It also requires time obtaining the form, figuring out where to send it, and filling it out. All of these are hassles that drive patients to not bother submitting the claim or avoiding people who are out of network. This last point is a problem for independent doctors and others who are trying to get by but don't have the capacity to be negotiating contracts every day with insurance carriers.

What is Reimbursify?

The problem of people not knowing how to file claims caused all sorts of difficulties with my guest today, Dr. Vatsal Thakkar (previously of episode 112 where we discussed Vitamin D). Psychiatry is often out of network with insurance carriers so driving patients into a practice can sometimes be very difficult. Dr. Thakkar began to offer the service of filing claims for his patients which, much to his surprise, drew a lot of patients to see him. He realized that if there was a way to automate the claims filing process for out of network billing, the he could provide a ton of value to both patients and health care professionals. Therein, Reimbursify was born.

What Does Reimbursify Do?

In the simplest explanation, reimbursify does all the claim filing for the patient. For a small flat fee it will take all the information required and make sure it goes where it is needed. It verifies that everything is filled out correctly and relieves the user of their anxiety from rejection from the insurance carrier. Health professionals can also sign up for the service which waives the flat fee for their patients' filing. In a way, this can serve as a way of replacing a billing office that would ordinarily be filing these same claims with in network insurance providers. Of course, the cost of this service is orders of magnitude less than what an actual billing office or staff would actually cost.