Billing > Facility Billing

Negotiation for out of network facility claim.

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HPATEL:
I have been working for out of network ASC. We are sending out facility claims. Sometimes we get payment or determination directly through the insurance company. Sometimes we get contacted by some third-party negotiators. I have been dealing with them for over a year now.
My question is how do we know from patients insurance plan that his claim will go out for negotiations before we take an assignment?
What is the correct terminology that we can ask the patient carrier when we call for eligibility?

PMRNC:
I don't think they can tell you until the claim comes through, it depends on their process for DRG audits and their out of network procedures for negotiating, some do it random, some do it by amount, etc. You can ask them what their process is for out of network fee negotiations.

HPATEL:
No, they won't tell me anything beforehand. I tried calling them with several different time with different scenarios. They only tell me reimbursement policy for OON facility claim is either U&C or MNRP.

Thank Your feedback though.

PMRNC:
Right, carriers are not allowed to give out U&C. You have to fly blind sort of. Remember though you don't have to negotiate rates, anything above U&C can be billed to the patient if you do not have provider contracts.

HPATEL:
Actually, Linda, I would prefer negotiating with them so the patient won't be liable for anything after their ded and oop. That is why I wanted to know before we take an assignment.

Thank You

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