Author Topic: Negotiation for out of network facility claim.  (Read 3643 times)

HPATEL

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Negotiation for out of network facility claim.
« on: February 09, 2018, 01:33:12 PM »
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?
« Last Edit: February 12, 2018, 02:45:03 PM by HPATEL »

PMRNC

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Re: Negotiation for out of network facility claim.
« Reply #1 on: February 13, 2018, 12:25:34 PM »
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.
Linda Walker
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HPATEL

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Re: Negotiation for out of network facility claim.
« Reply #2 on: February 13, 2018, 02:08:20 PM »
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

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Re: Negotiation for out of network facility claim.
« Reply #3 on: February 14, 2018, 08:35:12 AM »
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.
Linda Walker
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HPATEL

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Re: Negotiation for out of network facility claim.
« Reply #4 on: February 14, 2018, 10:39:45 AM »
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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Re: Negotiation for out of network facility claim.
« Reply #4 on: February 14, 2018, 10:39:45 AM »

HavenBilling

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Re: Negotiation for out of network facility claim.
« Reply #5 on: March 03, 2018, 09:59:54 AM »
Have you ever requested a single case agreement or letter of agreement. We do this quite often with out of network members because there is not another facility close enough to them. I don’t know if that’s a possibility for you, but we do a lot of LOAs and negotiate our rate up front and sign an agreement for the member to use their in network benefits.

PMRNC

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Re: Negotiation for out of network facility claim.
« Reply #6 on: March 03, 2018, 11:48:03 AM »
A single case agreement is good idea..works sort of like a pre-determination of benefits. You send them the CPT codes and they tell you yes or no they are within U&C. They won't tell you the U&C amount for this type of arrangement. I would def get any agreement in writing. They will not just arbitrarily give you a "fee schedule amount" because they can't. They don't because if they come back with a price that's higher than your actual fee (I know it's not likely but that's their preception) you will bill that amount and that wouldn' t be right. You need to let them know the fees that you charge that is not going to be unavaidable if you want to negotiate. Not all carriers will negotiate out of network rates and more times the patient has better success in getting the approval first to go out of network. If they don't or won't negotiate than you can have patient do a hardship and write off the amounts over U&C. As long as this is not done routinely and on case by case basis following hardship and documentation this would be perfectly acceptable to do.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Michele

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Re: Negotiation for out of network facility claim.
« Reply #7 on: March 03, 2018, 09:19:22 PM »
We have seen these single case agreements in areas where there are no in network providers.  The insurance carrier will give auth and approve a fee schedule amount on a per case agreement for a provider who is not in network if they cannot find an in network provider in the area that can take the patient.
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HPATEL

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Re: Negotiation for out of network facility claim.
« Reply #8 on: March 07, 2018, 02:13:15 PM »
Yes, That is what I had an understanding. They only give out single case agreements in areas where there are no IN-Network providers.  So far I figured out for Aetna and BCBS and United. But United is dicey. since they change their policy in the beginning of 2018.


bvikash

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Re: Negotiation for out of network facility claim.
« Reply #9 on: March 19, 2018, 04:59:14 PM »
Actually it is very hard to negotiate claims for out of networks, however we can still refer fair health prices as many company follow it like Cigna. We can also refer our old claims data and let the insurance company know that what they were paying previously and they cannot pay less. We can also refer to Mental Health Parity and Addiction Equity Act (MHPAEA) LAW.
Vik
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Re: Negotiation for out of network facility claim.
« Reply #9 on: March 19, 2018, 04:59:14 PM »

bvikash

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Re: Negotiation for out of network facility claim.
« Reply #10 on: March 21, 2018, 04:44:04 PM »
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?


While verifying the benefits for the patient we can ask the insurance rep whether this will be priced by third party or will be paid as per U&C rates or medicare rates. We are using it and it works.
Vik
vik.b@vertexhealth.net

HPATEL

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Re: Negotiation for out of network facility claim.
« Reply #11 on: March 21, 2018, 05:58:44 PM »
Thank you Bvikash.

BikhamHCare

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Re: Negotiation for out of network facility claim.
« Reply #12 on: March 21, 2018, 06:24:36 PM »
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Re: Negotiation for out of network facility claim.
« Reply #12 on: March 21, 2018, 06:24:36 PM »