Why is the out of state any different?
What can be done to make out of state coverage work? (I have no problem with billing the patient directly if the insurer doesn’t follow thru fast.)
Because there is no underlying contract.
Each hospital has contracts with nearly every major payer in their area. Sometimes, they don’t have contracts for very specific reasons. One of my clients is not contracted with the third largest payer in their state, because the reimbursement is too low. They will take patients in the ER, but don’t allow any surgeries, inpatient stays, pt, other services.
So, when Blue Shield of California starts selling plans in South Carolina, and hospitals in Columbia start getting paid based on “usual and customary,” all hell is going to break lose, and I’m going to get very rich.
Actually, I’m going to get very busy, but I probably won’t make any money because these end up with local counsel or in self pay.
As for billing patients....hospitals are actually loathe to submit huge bills to patients if it can be avoided. For one, they don’t get paid. Secondly, they don’t want to destroy their reputation in the community, particularly if they are in a competitive environment.
That last sentence is important. Actually billing patients is a dangerous business practice.