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OON provider reimbursement

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midwifebiller:
I bill for out-of-network providers. Some insurance carriers reimburse a % of their U&C, others reimburse a % of what was actually billed. Of course, we prefer the latter. Is there a way to "encourage" all insurance carriers to reimburse a % of our fee, not their U&C?

~Kelli

Michele:
Only in our dreams!  :)

If that were possible all providers would be out of network.  There is no way to dictate to an insurance company how we want our claims processed.  Especially out of network providers.  They have no leverage.  If you par, then you have a contract with the carrier and you can (in some cases) negotiate your rates, but non par, they have no incentive to make you happy.

Michele

thatcuteblonde:
The only thing I've been able to do is to argue the amount they consider R & C is less than average for the geo area. Wish I had soemthing more helpful. On the same subject, if you aren't contracted can an insurance company like UHC give you different 'allowed' amounts based on the same CPT code?

Michele:
It may vary per plan. 

Michele

PMRNC:
U&C (R&C) is different from fee schedules with In-Network carriers.
U&C is calculated based on a formula using the HIAA, while a fee schedule is a set fee per service the carrier sets for Par providers.
U&C can be appealed for higher reimbursement, with fee schedule allowable you can only try and re-negotiate the contract, and of course make sure they are allowing the actual fee schedule amount.
If a claim is denied or cut for U&C, then it was not processed as an IN Network claim/provider

Linda Walker
PMRNC
www.billerswebsite.com

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