Medical Billing Forum

Billing => Facility Billing => Topic started by: HPATEL on February 09, 2018, 10:33:12 AM

Title: Negotiation for out of network facility claim.
Post by: HPATEL on February 09, 2018, 10:33:12 AM
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?
Title: Re: Negotiation for out of network facility claim.
Post by: PMRNC on February 13, 2018, 09:25:34 AM
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.
Title: Re: Negotiation for out of network facility claim.
Post by: HPATEL on February 13, 2018, 11:08:20 AM
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.
Title: Re: Negotiation for out of network facility claim.
Post by: PMRNC on February 14, 2018, 05:35:12 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.
Title: Re: Negotiation for out of network facility claim.
Post by: HPATEL on February 14, 2018, 07:39:45 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
Title: Re: Negotiation for out of network facility claim.
Post by: HavenBilling on March 03, 2018, 06:59:54 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 donít know if thatís 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.
Title: Re: Negotiation for out of network facility claim.
Post by: PMRNC on March 03, 2018, 08:48:03 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.
Title: Re: Negotiation for out of network facility claim.
Post by: Michele on March 03, 2018, 06:19:22 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.
Title: Re: Negotiation for out of network facility claim.
Post by: HPATEL on March 07, 2018, 11:13:15 AM
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.

Title: Re: Negotiation for out of network facility claim.
Post by: bvikash on March 19, 2018, 01:59:14 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.
Title: Re: Negotiation for out of network facility claim.
Post by: bvikash on March 21, 2018, 01:44:04 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.
Title: Re: Negotiation for out of network facility claim.
Post by: HPATEL on March 21, 2018, 02:58:44 PM
Thank you Bvikash.
Title: Re: Negotiation for out of network facility claim.
Post by: BikhamHCare on March 21, 2018, 03:24:36 PM
Affordable Care Act in full swing, many consumers are surprised by the changes in coverage hidden in the fine print or couched in terms that are confusing. There are a lot of things to consider when choosing a policy. Even if you are covered, getting reimbursed can be challenging. Here are a few things to consider and some tips to get the most out of your coverage.

Terminology:In order to pay for more preventive services and to comply with the regulations, more and more companies are coping by shifting costs to employees and consumers. When choosing a policy and when choosing providers, you must understand your coverage. Here are some definitions from Healthcare.gov. I have added questions to ask.


Type of coverage - HMO, EPO, PPO, etc determines if you can use in or out of network providers, if you need a referral for specialists. Determine if your providers are in the plan and how much flexibility you want or need. Don't go by cost alone as you may find yourself in a plan with none of the providers you want or need.

Deductible- The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1,000, your plan won't pay anything until you've met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services. Ask which services do not go towards the deductible and which do. Only allowed services will go toward the deductible.

Co insurance - Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. Not only covered services require co insurance and it is payable only on the allowed amount.