6 Ways To Improve Your Out-Of-Network Reimbursements

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2 Min

The Out-of-Network VS. In-Network world in healthcare is changing
Source: Wakefield
May 26, 2024

Payer Tactics To Decrease Your Revenue

Let’s first talk about the tactics payors use to decrease your revenue. The vendors who work for the insurance companies to reduce out-of-network (OON) payments, such as Viant and Multiplan, each receive over 10 million out-of-network bills each year.

Every time a new bill is received, these vendors use computer algorithms to determine which of two tactics will yield the lowest possible payment to the provider.

One tactic they use is to negotiate a settlement in exchange for the provider agreeing not to balance bill the patient for the discounted amount. In other words, the insurance company tries to negotiate fees AFTER services are provided and AFTER the patient leaves the facility, but before the insurance company makes a payment. Typically, they fax a proposed settlement offer to you, often with a short turnaround time.
Secondly, they will simply re-price the bill down to “reasonable and customary” which is typically close to the Medicare rate. In other words, the insurance company re-prices the out-of-network bill down to 30% or less of billed charges based on their determination of what is “reasonable and customary.”

Another tactic is to hire senior professionals who used to work for providers.

They know A LOT about you. Their database tracks EVERY past negotiation. So, when an out-of-network bill is input, a screen pops up with the names, titles, and phone numbers of everyone in your business office.

For example, the screen may say, “don’t go to Mary, she will only give a 30% discount. Go to Bill. He will give 60%.”

bill hospital

How You Can Combat Surprise Billing

Becker’s states that “The No Surprises Act went into effect Jan. 1”. That being said, what are some ways we can combat the insurance companies? Here are some keys to help improve your out-of-network payments.

1. Persistence
The first key is what we like to call the persistence game. Who’s going to win the battle of the wills? Payers and vendors put up obstacles to success, banking – literally – that you will get up and walk away. Their goal is to get you to throw in the towel. They know you’re busy and don’t have the time to continue the fight.

It’s also important to note that the vendors are paid on a commission basis – your low reimbursement means their high commission. Essentially, when you give up, they win. Ultimately, to succeed, you must have the persistence to continue fighting for the reimbursement you deserve.

For example, when negotiating settlement offers respond to every counter-offer because they are hoping to wear you out by going back and forth multiple times in a short time frame. For appealing underpayments, a common delay tactic used by insurance companies is it to tell you the claim is still processing and to check back in 10, 15, 30 days. Many providers drop the ball after the 2nd or 3rd time they are told this. But if you stay with it, you will see results.

2. Specialized Out-of-Network Staff
Our next key is having staff that is specialized in out-of-network. It is a WHOLE different ballgame from your managed care contracts. For example, to be successful, it’s important to know:

· How have you historically been reimbursed for similar services?

· What type of policy does the patient have?

· If it’s a Medicare based policy, what percentage of Medicare does it reimburse?

· When is it best to write or call the payer?

· What are the best arguments to make?

· How do I decode the EOB so I initially understand why the insurance company reimbursed me this way?

· And when is the right time to escalate internally at the payor or externally, like with the state insurance commission or US Department of Labor?

3. Track Your Comparable Data
Thirdly is to obtain data to prove that the insurance company’s payments are inadequate. We have an incredible amount of comparable data because we’re aggregating data and results from the customers we service in our CRXIS database. Using data and analytics to compare our determination of reasonable and customary with the insurance company and, in many cases, we’re able to identify “holes” in their data and convince them to increase their payment. To do this, you could create something as simple as a spreadsheet that tracks items like the service provided, billed charges, allowable (which is important because this is what you truly want to compare as opposed to the payment), insurance company, and if possible, the policy.

4. Get Patient Auth Forms Signed Early
As part of an on ongoing effort to make the appeal process more difficult, some of the major insurance companies are now requiring authorization for agents outside of the patient to appeal on their behalf. Yes, this is even if you provide a strong Assignment of Benefits. We were able to uncover this quickly since our negotiators have “insider information” from previously working for these insurance companies.

Therefore, in order to overcome this strategy, it would bode well to include the payer-specific authorization form to your welcome package to be signed by the patient. Just beware of pitfalls like needing a new authorization form for each DOS or not being able to use electronic signatures.

5. Terminate 3rd Party Agreements
In terms of 3rd party agreements, they actually hurt your reimbursements and are not a good strategy if you are taking an out-of-network approach. These contracts act as a “cap” to your reimbursements so you are never able to get compensated for more than your contracted rate.

Also, the agreements are written in a way that allow for additional cuts to your reimbursements on top of your contracted rate. Just look on their website, it explicitly says that the payers are their customers, not providers. Some of our providers have canceled their third-party contracts after starting with us, and it’s increased their reimbursements.

6. Develop a Rigorous Dispute/Appeals Process
The final key is to develop a rigorous appeal process. As the first point mentioned, persistence is key. But having a method to this madness is essential.

Payers are putting up obstacles to success banking that you will get up and walk away. First, make sure you have access to all the important documentation you may need to submit. Which includes the claim form, EOB, medical records, assignment of benefits, and patient authorization forms.

Then, contact the payer to verify the patient and bill information and obtain a verbal explanation for the basis of the reductions. Next, you want to devise the appropriate strategy for that claim.

This involves formulating the facts and arguments to be made to the payer. Which is also a perfect time to use your new comparable data tracking spreadsheet. Engaging with the payer is the most tedious part of this process. You want to present the relevant facts to the payer, but no one over there wants to make it easy. To be successful with appeal, you need to be able to call every day, write letters, escalate when necessary.

Once you present the information to the payer, it will take them weeks to months to internally reconsider their decision. Here is when they play the waiting game, telling you to follow up in 10, 15, 20 days. Make sure you have a strong follow up process. Not surprisingly, payers don’t always pay on time and in the correct amount.

When you are successful getting an additional payment, you need to follow-up with the insurance company to ensure that you are paid and in the amount you agreed to. Some providers sign off on agreements and then forget to follow up to make sure it was actually processed.

So there you have it…

Collect Rx helps providers get higher reimbursements on out-of-network bills to maximize payor collections. We don’t do this as consultants, but as experts in negotiating and appealing in order to achieve higher reimbursements on your bills and collections.

Founded by the originators of the out-of-network negotiations and appeals industry, we have been singularly focused on helping providers get higher reimbursements since 2006.

Helping more than 4,500 providers nationwide optimize their reimbursements for out-of-network collections.

With a variety of provider types, including surgery centers, emergency physicians, anesthesiologists, hospitals, and labs and we can help you too!