Author Topic: Mental Health/ Substance Abuse billing OON and multiplan  (Read 2651 times)

James B

  • Newbie
  • *
  • Posts: 23
Mental Health/ Substance Abuse billing OON and multiplan
« on: October 18, 2012, 06:03:55 PM »
I recently took over billing for a psychiatrist's office. He is out-of-network with all insurance companies. He had enrolled in Multiplan, but after seeing how much money he was losing, we recently canceled that agreement. The cancellation finally took effect 10 days ago. Around that same time, we received a discounted rate request via fax from Multiplan. They claim patient has no OON benefits unless we agree to their deep discount.

I called Multiplan who said the claim was sent to them from Cigna with a request to discount it by $113 (previously they had been discounting this fee by $90). I told them we don't want to accept this discount and they said that the request should then be faxed back as DECLINED.

The question is whether CIGNA can simply decline claim as OON if we don't accept--or can we simply say no thanks, pay in full--why should we discount? Do they have any leverage? Why would we accept discount for no reason?

EDIT: I just confirmed with Cigna that patient does have unlimited OON visits (so Multiplan id full of $%#*), that Cigna will play at 80% based on maximum allowable in the area. So I think that answers my question. I am still curious if anyone can offer any additional info about cancelling Multiplan. Thanks!

James

PMRNC

  • Hero Member
  • *****
  • Posts: 4562
    • One Stop Resources & Networking for Medical Billers
Re: Mental Health/ Substance Abuse billing OON and multiplan
« Reply #1 on: October 18, 2012, 06:55:22 PM »
Many plans will do a discount as in network on a case by case basis, yes you can decline so long as you know the patient can see an OON provider (make sure it's not an HMO) To be EXTRA sure I would additional make sure the patient does their own checking on this because if it's not covered they will be responsible. I also would verify the benefits at the OON level. Remember that OON means they will pay up to U&C.. not necessarily a % (coinsurance) of the Fee. OON using U&C which you have no control over. That us usually one of the main reasons providers par with managed care, many times the allowable is higher than the U&C. NOT ALWAYS.. but majority of time.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Michele

  • Administrator
  • Hero Member
  • *****
  • Posts: 5927
    • Solutions Medical Billing
Re: Mental Health/ Substance Abuse billing OON and multiplan
« Reply #2 on: October 19, 2012, 09:44:21 AM »
We receive many of those faxes.  We (Almost) never accept.  IMO the information on the fax is misleading.  They do not pay what is on the fax, they ALLOW what is on the fax and then apply OON benefits.  Also, many times the claim is paid by the insurer BEFORE we get that fax.  They call us and ask "Why don't you want to take the offer?"  They drive me nuts!
Sign Up for our FREE Medical Billing Newsletter
Get a 10% discount on Medical Billing Products by using Coupon Code: 10OFF
http://www.solutions-medical-billing.com

PMRNC

  • Hero Member
  • *****
  • Posts: 4562
    • One Stop Resources & Networking for Medical Billers
Re: Mental Health/ Substance Abuse billing OON and multiplan
« Reply #3 on: October 19, 2012, 11:58:23 AM »
I have never seen random ones, usually the patient has contacted the carrier and then the carrier contacts the client, but your right, many times the negotiated rate is not really beneficial to the provider. I've not seen ones where it' doesn't spell out the allowable. Usually we will see either them negotiating an In network rate with authorization.    The only time this is beneficial to the provider is if he has at least a handful of returning patients OR if there is high dollar claims for example a surgeon, etc.  You should be careful though in reviewing them. Many times if you deny the fee you might also be denying the authorization along with it.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Medical Billing Forum

Re: Mental Health/ Substance Abuse billing OON and multiplan
« Reply #3 on: October 19, 2012, 11:58:23 AM »