Out-of-Network: Frequently Asked Questions€¦ · Out-of-Network –the provider has not...
Transcript of Out-of-Network: Frequently Asked Questions€¦ · Out-of-Network –the provider has not...
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Out-of-Network: Frequently Asked Questions
November 2017
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Collect Rx Out-of-Network Background
General Out-of-Network Issues
Payment Processing
Policies
Negotiating Settlement Offers
Appealing Underpayments
Third-Party Rental Network Agreements
Topics
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Collect Rx Out-of-Network Expertise
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Collect Rx: The Out-of-Network Experts
• Focus: helping providers maximize reimbursements on out-of-network bills
• Started in 2006
• More than 1,300 customers nationwide
• Customers include ambulatory surgery, physician groups, hospitals, and labs
• Created CRXIS™ proprietary OON database
• Built team of experts who formerly worked for insurance companies and their vendors
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FAQs: General
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Out-of-Network – the provider has not negotiated a contracted rate for reimbursements with the payer
Repricing – payer reimburses lower than the provider’s full billed charges
Vendors – companies used by payers to reduce payments to providers
Single case rate agreements – payment offers negotiated by the payer and provider before payment is made
Definitions
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What is the #1 key to successful out-of-network negotiations?
Persistence
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Frequently Asked Questions: General
If I am currently OON and there is no Third-Party Rental Agreement, is there still
a strategy to negotiate?
Yes: negotiate or appeal
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Frequently Asked Questions: General
What’s the best way to negotiate with payers: phone, email, or fax?
Phone
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Frequently Asked Questions: General
Is it worth the trouble negotiating if we don’t see a lot of OON?
Yes
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Frequently Asked Questions: General
Can I do anything if the bill was denied for no authorization?
Sometimes
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Why would I want to be Out-of-Network?
More Money
Frequently Asked Questions: General
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FAQs: Payment Processing
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Frequently Asked Questions: Payment Processing
How do payers determine what to pay?
Employer preference
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How can 2 patients with the same treatment and the same insurance
company have 2 different reimbursements?
Reimbursements levels are determined by the employer group
Frequently Asked Questions: Payment Processing
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My revenue cycle team insists that “Usual & Customary” is limited to 150% of
Medicare or lower for OON. What are your thoughts?
Frequently Asked Questions: Payment Processing
UCR is misconstrued by many providers
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Frequently Asked Questions: Payment Processing
How do you collect more than Usual & Customary?
Data, policies, and expertise
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FAQs: Policies
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What is a limited benefit policy?
Frequently Asked Questions: General
Puts restrictions on the calculation of reimbursements
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Frequently Asked Questions: General
What are example of limited benefit policies?
United Healthcare MNRPCigna MRC
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Frequently Asked Questions: General
How do I know if the patient has a limited benefit policy?
Ask during benefit verification
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Frequently Asked Questions: General
Can cases involving international patients be negotiated?
Yes
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FAQs: Negotiating Settlement Offers
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Frequently Asked Questions:Negotiating Settlement Offers
What is the incentive to agree to any of these proposals when the provider is OON
with the payer?
Maximize reimbursements
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Frequently Asked Questions:Negotiating Settlement Offers
Why would I negotiate offers from companies like Multiplan? I expect 100%
of my charges.
Bill minimization tactics allow payers to reimburse at a fraction of your charges
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Frequently Asked Questions:Negotiating Settlement Offers
Any tips for negotiating the single-case agreements?
Persistence and data
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Frequently Asked Questions:Negotiating Settlement Offers
What do you think about our strategy of never accepting more than 10% discounts?
Bill minimization tactics allow payers to reimburse at a fraction of your charges
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Won’t negotiating aggressively ruin my relationship with these vendors?
They are not your friend
Frequently Asked Questions:Negotiating Settlement Offers
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Is it appropriate that vendors often give me less than a day to negotiate?
Some expiration dates are real, some are not
Frequently Asked Questions:Negotiating Settlement Offers
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Once we agree to a discount, can the payer change their mind?
Yes
Frequently Asked Questions:Negotiating Settlement Offers
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If we decline a single case agreement, can we bill the patient?
Yes
Frequently Asked Questions:Negotiating Settlement Offers
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If we accept a single case agreement, can we bill the patient for the discounted
amount?
No
Frequently Asked Questions:Negotiating Settlement Offers
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Is it better to decline an agreement if we don’t agree with the reimbursement
amount?
Yes and no
Frequently Asked Questions:Negotiating Settlement Offers
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Is it good to sign up with third-party portals?
No
Frequently Asked Questions:Negotiating Settlement Offers
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FAQs: Appealing Underpayments
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As an OON provider, can we appeal low reimbursements for claims?
Yes
Frequently Asked Questions:Appealing Underpayments
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Frequently Asked Questions:Appealing Underpayments
What’s the best way to successfully appeal underpaid bills?
ResourcesData
MethodPersistence
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What are best practices to appeal an underpayment?
Rigorous appeal process
Frequently Asked Questions:Appealing Underpayments
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Docs
Appeal Process
• UB / CMS1500• EOB• AOB• Billing Notes• Collections Notes
Frequently Asked Questions:Appealing Underpayments
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Docs
Payor Verification
Appeal Process
• Verify patient info• Verify bill info• Verbal explanation
of reductions
Frequently Asked Questions:Appealing Underpayments
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Docs
Payor Verification
Strategy
Appeal Process
• Gather facts & data• Formulate arguments
to the payer
Frequently Asked Questions:Appealing Underpayments
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Docs
Payor Verification
Strategy
PayorEngagement
Appeal Process
• Call everyday• Write letters everyday• Escalate• Takes several weeks
Frequently Asked Questions:Appealing Underpayments
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Docs
Payor Verification
Strategy
PayorEngagement
Settlement &Follow-up
Appeal Process
• Make sure you are paid in the correct amount!
Frequently Asked Questions:Appealing Underpayments
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What is an Assignment of Benefits?
Frequently Asked Questions:Appealing Underpayments
Ensures you are paid
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Any tips on the Assignment of Benefits?
(1) Assigns the provider all rights under the insurance policy(2) Refers to the provider as the patient's authorized representative(3) References ERISA and a full and fair review of claims
Frequently Asked Questions:Appealing Underpayments
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What about insurance companies paying initially, but then recouping the money
later?
Frequently Asked Questions:Appealing Underpayments
Appeal the refund request
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FAQs: Third-Party Rental Agreements
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What is a Silent PPO (or Third-Party Rental Agreements)?
An insurance company tactic to lower reimbursements by accessing the discounted rates of another insurer, typically without the
provider’s knowledge
Frequently Asked Questions:Third-Party Rental Agreements
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How do I know when a Third-Party Rental Agreement is going to be applied?
You don’t
Frequently Asked Questions:Third-Party Rental Agreements
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Why do so many providers contract with 3RD Party Rental Agreements / Silent
PPO’s?
It’s easy
Frequently Asked Questions:Third-Party Rental Agreements
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Why don’t the payers always use my third party contract?
The contracts are caps on reimbursements
Frequently Asked Questions:Third-Party Rental Agreements
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Why does the EOB sometimes state the third-party contract was used, but the bill
was not reimbursed according to the contract?
Vendors employ various cuts
Frequently Asked Questions:Third-Party Rental Agreements
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How do I track if my Third-Party Rental Agreements are being applied correctly?
Check your EOBs
Frequently Asked Questions:Third-Party Rental Agreements
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Why do I receive settlement offers when I have a contract?
Payers are trying to beat the contracted rate
Frequently Asked Questions:Third-Party Rental Agreements
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A Word About Outsourcing
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Richa Singh, EVPCollect Rx
Note: This presentation is not providing any legal advice and viewers should consult with their own lawyer for legal advice.
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How can an insurance company create an “Allowed” amount that is different than
the patient’s plan document?
Frequently Asked Questions: Payment Processing
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Frequently Asked Questions: General
We have seen OON reimbursements decrease for the same procedures over
time. How is that possible?
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Commonly Asked Questions
Should I outsource out-of-network negotiations?
Provides more time for patient care
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Commonly Asked Questions
What should I take into account
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Frequently Asked Questions:Negotiating Settlement Offers
What is a single case agreement?
Negotiate after services, but before payment