Author Topic: OON provider reimbursement  (Read 2026 times)

midwifebiller

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OON provider reimbursement
« on: May 04, 2009, 09:27:56 PM »
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
Kelli Sugihara, CPMB
Midwife Billing & Business, LLC
www.midwifebilling.com

Michele

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Re: OON provider reimbursement
« Reply #1 on: May 05, 2009, 06:49:33 AM »
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
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thatcuteblonde

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Re: OON provider reimbursement
« Reply #2 on: May 05, 2009, 09:44:37 AM »
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

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Re: OON provider reimbursement
« Reply #3 on: May 05, 2009, 12:03:08 PM »
It may vary per plan. 

Michele
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PMRNC

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Re: OON provider reimbursement
« Reply #4 on: May 05, 2009, 09:48:47 PM »
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
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Linda Walker
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midwifebiller

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Re: OON provider reimbursement
« Reply #5 on: May 06, 2009, 12:36:38 PM »
Thank you for your input! All said, we have had good results by having the member work with their HR department for higher reimbursement. Since these are non-par, non-solicited providers (they won't contract with us even if we wanted to), HR will usually work with their members and then the carriers for the better reimbursement rates. I was just hoping there was an easier way, but it doesn't sound like it.  Thanks again!

~Kelli
Kelli Sugihara, CPMB
Midwife Billing & Business, LLC
www.midwifebilling.com

PMRNC

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Re: OON provider reimbursement
« Reply #6 on: May 07, 2009, 05:48:59 AM »
No, when you are non-par and you decide to appeal U&C you are actually doing it as a "courtesy" to the patient since they are typically getting a bill for the balance. (should be anyway)
With Surgical charges that have been cut for U&C you usually would send an op report with your first appeal along with a letter. In many cases the carrier will then issue another payment so it's always worth "a shot". Sometimes the patient is good for a second appeal since it is technically them appealing the claim cut back.

Linda Walker
PMRNC
www.billerswebsite.com
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

midwifebiller

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Re: OON provider reimbursement
« Reply #7 on: May 08, 2009, 08:20:52 AM »
Linda--Yes, everything we do is courtesy to the patient, but it helps our midwives with their businesses. Especially as the economy gets tighter, more people are wanting their insurance to cover midwifery care (most do) at the in-network rate (this is the tricky part) or at least a 'good' rate. We have not tried appealing the U&C after reimbursement; that might be easier than trying to obtain in-network exceptions, HR exceptions, etc., before submitting the claim.

Thanks again for your input!

~Kelli
Kelli Sugihara, CPMB
Midwife Billing & Business, LLC
www.midwifebilling.com