Author Topic: Out of network rate  (Read 1912 times)

claudiajg1

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Out of network rate
« on: September 20, 2013, 04:55:07 PM »
We are out of network with Aetna and Cigna, our managers at work want us to appeal any out of network claims that pay less than 80%.

I did a quick research on Aetna and I found that they pay out of network based on FAIR Health Inc. This non-profit company basically collects data based on types of procedure in a specific zip code. They pay based on the "reasonable , prevailing" charge. For example the prevailing charge for CPT 00740 in zip code 10033  is $1809.00 and they pay 70%. The estimated payment will be $1266.30.

It seemed pretty simple, even if we bill $2450.00 for this procedure we will only consider $1809 because that's the customary charge in that area. And since they only pay $1266.30 the pt's responsibility will be the difference (which our office will write off bc we don't bill pts for out of net resp. as long as the insurance pays).

However I called Aetna on a claim that we only received $450.00. The rep said this patient had  Open Acces Select PPO plan and they paid at the Medicare 125% rate.

Basically I was trying to see if there was a way of knowing what we will get so that we wont have to leave all those claims open in our system. Also to see if we could know so we wont have to call and appeal for every single claim that pays less than 80% (like they asked us to do)

How can we know if the Fair Health estimate applies or the Medicare 125% rate applies for these out of network claims?

rdmoore2003

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Re: Out of network rate
« Reply #1 on: September 23, 2013, 02:52:06 PM »

It seemed pretty simple, even if we bill $2450.00 for this procedure we will only consider $1809 because that's the customary charge in that area. And since they only pay $1266.30 the pt's responsibility will be the difference (which our office will write off bc we don't bill pts for out of net resp. as long as the insurance pays).



Is this part even legal??
Regina

PMRNC

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Re: Out of network rate
« Reply #2 on: September 23, 2013, 04:07:06 PM »
This is NOT a simple topic.

Usual and Customary(U&C, or UCR) (sometimes referred to as Reasonable and Customary (R&C) refers to the base amount that third-party payers (including insurance carriers and employers) generally use to determine how much will be paid for reimbursable services.  This amount is calculated based on review of prevailing charges of OTHER physicians in a particular service and area(geographical area)   UCR/R&C is set at the 80-90th percentile of that amount (collected in data .. I think the most recent prevailing data is from 1994, don't quote me on that)

Now you can try to figure this out but it would be much easier to bang your head on the wall.

With NON par and U&C/R&C remember that the amount OVER U/C and R&C is patient responsibility. IF your provider is PAR, then it's fee schedule and the amount over fee schedule and minus patient OOP is your adjustment (write off)

With amounts OVER U&C you can bill the patient. But..before you do that there are a few things you can do..

First with any major procedure (set a policy in the office of for example procedures over $500) send the carrier a per-determination of benefits. For a Pre-d, you want to send the procedure codes that will be anticipated and billed and the amount of the procedure. Sometimes carriers will take these via fax, call first and find out their procedure.
The carrier will then give you a written YES or NO that the fee is within the U&C amount and how much is OVER U&C, or that the fee is within U&C. For example if you give them a procedure and price of $500 they will either tell you it's $-- OVER U&C or the fee is within U&C. They don't want physicians inflating charges if the fee is within by telling you what the U&C is if it's more than your fee for that procedure.

From that point your patient should know what their OOP will be. Later on if complications arise or they cut the fee more than they should have you can file an appeal. The carrier will tell you what they need to determine if additional monies are to be paid out. Sometimes with a large U&C cut the provider can get a bit more out of the carrier with either notes or an operative report. You want to include any additional information NOT sent with the original claim that justifies the added fee.

Again, keep in mind the amount OVER U&C is considered patient responsibility and is a part of their COST sharing so NOT billing them can be a violation of their policy. Providers should always make reasonable attempts to collect patient OOP.
« Last Edit: September 23, 2013, 04:09:52 PM by PMRNC »
Linda Walker
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claudiajg1

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Re: Out of network rate
« Reply #3 on: September 25, 2013, 10:39:23 AM »
Unfortunately our managers don't know much about billing and collecting (sad I know). Our boss had several consultants coming in and telling him that we had to attempt collecting from the pt and we did this while the consultant was here but when she left things went back to normal. Basically we provide anesthesia for different doctors offices and they were upset that we were billing their patients (that's only because our doctor told them we were in net when were weren't) so we stopped billing them. We only bill them if the insurance doesn't pay anything.

I will look into the per-determination of benefits. Thank you so much!

PMRNC

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Re: Out of network rate
« Reply #4 on: September 25, 2013, 01:35:32 PM »
Quote
Unfortunately our managers don't know much about billing and collecting (sad I know). Our boss had several consultants coming in and telling him that we had to attempt collecting from the pt and we did this while the consultant was here but when she left things went back to normal. Basically we provide anesthesia for different doctors offices and they were upset that we were billing their patients (that's only because our doctor told them we were in net when were weren't) so we stopped billing them. We only bill them if the insurance doesn't pay anything.

I get that ..but ULTIMATELY in/out network status responsibility falls on the patient. Depending on a lot of things it might be a good idea to make a reasonable attempt to collect from the patient, if appeals are necessary and within the appeals timeline you can offer this as a "COURTESY" to the patient. Legally speaking, to write these off w/out an attempt to collect could be trouble.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com