Out-of-network benefits

Some health care benefit plans administered or insured by affiliates of UnitedHealth Group Incorporated (collectively “United”) provide out-of-network benefits for United’s members.

United offers different out-of-network benefit options to meet the unique needs of its employer customers and members. Customers choose which plans to offer to their employees. Not all plans include out-of-network benefits.

When reviewing a claim for payment for a service provided by an out-of-network provider, United follows the member’s benefit plan. The member’s benefit plan will explain which services are covered out-of-network. (Some services are covered only when received from a network provider.) The member’s benefit plan will also explain how an out-of-network claim should be paid.

Out-of-network benefits typically use one or more of the following reimbursement databases, benchmarks, or methodologies to establish the reimbursement amount for out-of-network claims.^F91

CMS. The established and published rates and reimbursement methodologies used by The U.S. Centers for Medicare and Medicaid Services (“CMS”) to pay for specific health care services provided to Medicare enrollees (“CMS rates”). Benefit plans that use this benchmark use a percentage of the CMS rates for the same or similar service.

FAIR Health. The rate recommended by FAIR Health’s database. FAIR Health is a not-for-profit company, independent of United, that collects data for and manages the nation’s largest database of privately billed health insurance claims. FAIR Health organizes the claims data they receive by procedure code and geographic area. FAIR Health also organizes data into percentiles that reflect the percent of fees billed.  For example, the 70th percentile for a certain service means 70% percent of the fees billed by providers for the same service.  For additional information regarding the FAIR Health Benchmark Databases, please visit FAIR Health's website.

• Viant. A rate recommended by Viant, an independent third-party vendor that collects and maintains a database of health insurance claims for facilities, then applies proprietary logic to arrive at a recommended rate. Viant also organizes its data by percentiles.
• Negotiated Rate. The rate United or its vendors negotiate with an out-of-network provider after the service was provided. Whether a negotiated rate is available depends on the circumstances and applicable member benefit plan.
• Shared Savings Program or Third-Party Network Discounts. Sometimes United may have the right to access contracts and discounts that certain third parties have with out-of-network providers. When this program applies, the out-of-network provider's billed charges will be discounted.
• Pharmaceutical Methodology.  The rate used to pay pharmaceuticals administered by a physician or other healthcare professional. Most benefit plans use a methodology that establishes the reimbursement amount based on published acquisition costs or average wholesale price for the pharmaceuticals. These methodologies are currently created by RJ Health Systems, Thomson Reuters (published in its Red Book), or United based on an internally developed pharmaceutical pricing resource. A plan may use this methodology as either the primary or secondary methodology to reimburse these services. 
• Other Methodologies. These are typically used when the main methodology used by the benefit plan is not available or does not have a rate. They may include:
  • a methodology established by OptumInsight or a third-party vendor that uses a relative value scale. The relative value scale is usually based on the difficulty, time, work, risk and resources of the service. We and OptumInsight are affiliated companies through common ownership by UnitedHealth Group. 
  • a rate based on information from a third party vendor which may reflect one or more of the following factors: 1) the complexity or severity of treatment; 2) level of skill and experience required for the treatment; or 3) comparable providers' fees and costs to deliver care.
  • an amount based on the rate United pays its contracted providers for the same or similar service, adjusted as appropriate by geographic location.  This may be based on the median or average rate for the contracted provider.
  • a percent of the billed charges, when no other methodology is available.

By following the member’s out-of-network benefit plan, the maximum amount United will pay for a service, at times, will be less than the amount billed by the out-of-network provider. Members are responsible to pay their share of the out-of-network cost share. The provider may bill the member for difference, if any, between the amount allowed for the out-of-network service and the out-of-network provider’s billed charge. If a negotiated rate or third-party discount is used, a provider may not bill the member for the difference between the contracted rate and the provider’s billed charge.

There may be times when services from an out-of-network provider are covered under the member’s in-network benefits. This may include when a member receives emergency services, when we approve an out-of-network provider when a network provider is not available, or when the member has in-network services and, in the course of treatment, receives services from an out-of-network provider without the member’s knowledge or consent. In these instances, the member’s benefit plan will provide information on the member’s cost share obligation.

In-network benefits paid to out-of-network providers typically use one or more of the following reimbursement databases, benchmarks, or methodologies to establish the reimbursement amount:

• CMS. The CMS rate or a percentage of the CMS rate for the same or similar service. 
• Par Median. The median rate United pays its contracted providers for the same or similar service, adjusted as appropriate by geographic location. 
• Negotiated Rate. The rate United or its vendors negotiates with an out-of-network provider after the service was provided. 
• Third-Party Networks. As noted above, sometimes United may have the right to access contracts that certain third parties have with out-of-network providers. These rates may be used if the contract or discounted rate is lower than the plan’s benchmark for paying these claims. The assessment of whether a rate is available is done once the claim is submitted.
• Data iSight. The rate recommended by The Data iSight tool provided by a third-party vendor. The Data iSight tool is a patented pricing tool that recommends a reimbursement amount using paid claims data from millions of claims, from many different payers, for many different patients across a distribution of age, gender and location that reflects the U.S. Census. The tool recommends a reimbursement amount based on national benchmarking, regional wage, indexing and geographic adjustment, among other methods. The tool also provides transparent reporting to allow for an open dialogue with providers about the amount that the tool determines to be a reasonable reimbursement rate for the service. For additional information regarding the Data iSight Tool, please visit Data iSight’s website.

Reimbursement for out-of-network providers is subject to United’s reimbursement policies. Application of our reimbursement policies typically result in a decrease to the allowed amount. United’s reimbursement policies are generally based on national reimbursement rules and determinations, along with state government program reimbursement policies and requirements. Examples of the most common reimbursement rules include:

• If a single code describes a procedure and the provider bills several procedure codes, we may apply one inclusive amount rather than a separate amount for each billed code.
• If a surgery involves several different procedures, coverage for some or all of the procedures may be made through a single inclusive amount for the primary procedure. Some secondary procedures may be eligible for reimbursement at 50%.
• When services are received from a health care professional who is not a physician, such as a physician's assistant, the reimbursement amount will be less than what is allowed for a physician.

Our reimbursement policies can be found at UHCprovider.com/policies.