Many health insurance carriers with plans containing out-of-network benefits, like PPOs and POSs, utilize a system that reimburses patients for services rendered by non-participating physicians. At the time treatment is provided, patients pay the entire retail cost to the doctor, then they file claims with the carrier requesting reimbursement.
After receiving out-of-network treatment, patients complete standardized reimbursement claim forms detailing the specific services provided, dates and times of those services and their monetary outlay. Evidence of both the treatment received and money spent must be submitted along with the claim forms, allowing the insurance company's administration to examine the documentation and verify the services are eligible for reimbursement.
Difficulties and Expectations
Members covered under reimbursement-style health insurance plans should not expect to receive immediate or timely payment from the carrier. Many insurance companies take weeks, or sometimes months, to finish processing reimbursement claims and mail checks to patients. Acquiring or allocating the full cost of medical treatment to pay for covered services challenges many insurance company customers, as some services have extremely high price tags. Additionally, being forced to wait extended periods of time before receiving money back in the form of a reimbursement check may threaten a family's financial stability.
If your health insurance plan contains coverage for services provided by non-participating providers, you may still be required to pay in full for treatment at the time it is rendered, then wait for the carrier to reimburse you. The reimbursement process often takes several weeks, if not months, to complete.