Medical Billing Forum

Payments => Insurance Payments => Topic started by: camedbill on June 07, 2016, 02:42:01 PM

Title: Out of Netword Providers and Repricing Agreement
Post by: camedbill on June 07, 2016, 02:42:01 PM
Have anyone billed for out of network providers and receive Repricing Agreements from 3rd party price negotiator like PHx?
Do you normally accept these agreements or do you just go back to the orignal payor?
I'm asking because their fees are usually not that great and if accepted, you don't have the option to balance bill patients?
In other words, do we have to play ball with them or can we still go back to the payor for payments?
Thanks in advance for your help.
Title: Re: Out of Netword Providers and Repricing Agreement
Post by: Michele on June 08, 2016, 11:16:37 AM
We were just talking about this today!  I have always been a firm "no deal" person.  I just find the concept ridiculous.  I send a claim to a payer, they send it to somebody else, who then tries to deal with me (provider) for a lower fee for a "quick payment".  Really?  Cuz sometimes I've already gotten payment from the payer before I even get the request!  And what they don't tell you very clearly is that if the provider is out of network most likely it will still be applied to the deductible so the patient has to pay anyway so all you did was agree to bill the patient a smaller fee.  Which you can do if you want to but why should a middle man get something?   (Making sure no laws are broken.  If an amount is applied to the deductible you can't simply charge the patient less.)  But this week we found that one of these companies actually paid an out of network provider when if the carrier had processed it he would not have been paid.  So I don't know if something has changed recently or if this is a fluke.

Anybody else have any experience with this?
Title: Re: Out of Netword Providers and Repricing Agreement
Post by: juliemedex on June 28, 2016, 09:49:33 AM
I would like to get some firm procedures on how to deal with these entities. I have been told so many different things concerning out of network providers and how insurances can choose to pay any way they want.
I have been told by both large billing companies and one lady who has a national insurance auditing firm to set up global pricing agreements with Multiplan, TRPN or Stratose, Global Claims, etc and come to an agreement like 25 - 30% off the billed rate. This has actually worked for me and been beneficial.
That gives the provider some leverage(like having a contract with the carrier) to get a decent payment instead of the ridiculously low discounted rates we sometimes receive, especially from VIANT who Cigna likes to use.
THEN, I have also been told not to agree with the pricing and send claims back to carrier. You are then told by the carrier(Cigna) that they send all OON claims to be priced by third party and you are in a back and forth argument between the two and getting no clear explananation.  I have had Cigna pricing and paying claims at a reasonable rate for two months then they all of a sudden start having Viant try to negotiate saying the plan is actually an MRCII policy and if I don't accept the negotiation the claims will price at 110% Medicare. I argue and say Cigna can't do that, they have been paying 60% of my billed rate. They say well Cigna may have made a mistake and this is really an MRCII policy... I think they use language to persuade/scare you into thinking the carrier priced wrong to get you to accept.. So, I want to know what is the real deal with thrid party pricing. It make sense to me to get global agreements with some if you can arrive at a good percentage of your billed amount but it doesn't mean all claims will price that way. Sometimes it still depends on the policy.  I have never been able to get a reasonable agreement from Viant and hence my frustration with them in particular.
Appreciate any feedback...
Title: Re: Out of Netword Providers and Repricing Agreement
Post by: PMRNC on July 01, 2016, 10:58:12 AM
The idea of non-participating with certain carrier panels is to avoid all that nonsense. For claims submitted w/out a contract patient is responsible for anything left over.. end of story. If a fee is reduced due to U&C, as a courtesy the provider can appeal it for a patient.

Title: Re: Out of Netword Providers and Repricing Agreement
Post by: EZlabor on August 26, 2016, 10:18:43 AM
Best not to negotiate, but I have to advise on my experiences and leave that up to the facility. They will slow pay you into madness at times. I have seen people say no to these deals of 60% and then receive 30%.
  I agree, it is nonsense. I started to get these in 2012? for substance abuse. The negotiator would tell me this was the most they could pay or if I don't agree the claim will take longer to process. I thought noo way...yes they did. I started to agree to 95% of claim IF paid in 10 days. Write that on there and it worked. Then it stopped. It began to become an opening conversation to more pain.  In 2014 they started to tell me it would pay at medicare rates if I didn't agree. just lunacy. I had an owner, scared, respond to a fax and negotiate. They then kept score with his agreement percentage and it was a constant headache. I say, at this time, do not negotiate. Its almost like bill collectors back in the lawless as that it seems. Yes they have tried to do seemingly, blatantly illegal things.
 The "negotiators" always toss out Medicare rates scare. I ask, then what is there to negotiate unless you are MISREPRESENTING THE TRUTH ;) - I know that to not be true. Please stop harassing and forward payment immediately. You are causing the provider undue hardship by delaying payment. -Now that is working. Maybe not tomorrow....we shall see.
Title: Re: Out of Netword Providers and Repricing Agreement
Post by: rdmoore2003 on August 26, 2016, 10:56:08 AM
I receive these by fax.   For years, I would call them and ask them to take us off of the fax list since we do not take these agreements.   Of course, they tell us that it is a claim by claim basis.    We do not accept any of these agreements.  There is no contract, therefore, you are not required to accept any of these "agreements"
Title: Re: Out of Netword Providers and Repricing Agreement
Post by: Michele on August 29, 2016, 08:51:46 AM
This is one of my pet peeves!  Drives me crazy.   >:( >:( >:(  They also call us!  They use the "you'll get paid faster" tactic.  If the insurance carrier just paid the claim instead of sending it to you it would have been paid by now.  Also, sometimes the claims are paid when we get the fax!   :o
Title: Re: Out of Netword Providers and Repricing Agreement
Post by: PMRNC on August 29, 2016, 01:17:50 PM
For my clients that are NON par we have devised a system that will allow the practice to submit a predetermination of benefits to the carrier. We submit the CPT code and our pricing along with a request for a pre-determination and the carrier is obligated to let us know that YES or NO the charge is within U&C or not within U&C. The carrier is NOT obligated and will not give us the U&C (to prevent fraudulent billing) but they will tell us yes or no the fee is within U&C. Using that we can tell the patient  ahead of time they will be required to pay the difference and all other out-of-pocket expenses. This really cuts down on our patient statements as we can tell the patient they are required to pay the difference between the billed amount and the amount the insurance carrier allows as U&C.  MANY of the TPA's will let you fax these and many times you can get a response almost immediately. We don't bother with the out of network repricing requests. This procedure allows us to find out ahead of time what the patient is responsible for.  On a rare occasion if the patient has an EAP plan we will negotiate with the EAP plan.