Author Topic: Out Of Network Surgery Claims  (Read 3572 times)

PippiT

  • Newbie
  • *
  • Posts: 26
Out Of Network Surgery Claims
« on: December 17, 2015, 10:15:33 AM »
Hi! I need help! I am very new to the medical billing world. I've been lurking for a few weeks trying to search for answers and am now at a roadblock and need some expert advice.

Can someone please explain to me Out of Network Claims and how to get them paid? I am spinning my wheels. My provider insists to be paid whatever percentage the patient's out of network benefits are for the billed amount. Let's say the plan pays 80% for out of network.

I have 3 Out of Network claims from two different insurances and I've been going back and forth with for two months and cannot get these paid. All 3 were sent to Multiplan/Viant.

One claim was sent to Viant and we have been trying to get it repriced through the insurance. The insurance said their hands are tied that the patient's employer chose a network savings program plan and that we have to appeal to Viant.

The other two claims also went to Viant, but we were able to get it back to the insurer to reprice and they repeatedly deny saying the claim was processed correctly. One used MNRP rates to pay out of network claims.

I just don't understand. My trainer says she just keeps calling until she gets the right person to help her. I am horribly confused and have no idea how to navigate the system.

If we do not have a contract how can they pay by whatever rates they deem appropriate? Thank you in advance!!





 

PMRNC

  • Hero Member
  • *****
  • Posts: 4254
    • One Stop Resources & Networking for Medical Billers
Re: Out Of Network Surgery Claims
« Reply #1 on: December 17, 2015, 02:09:55 PM »
You don't give specific reasons for denial or reduction. OUT of network benefits are subject to U&C (Usual and Customary). Are you getting full denials on full charges? That could indicate it's an HMO where the patient may not have out of network benefits. Are you getting "reductions"? If so you can appeal U&C reductions but ultimately the patient is responsible for payment, how you appeal it depends on a variable of things. Are these high dollar claims? Surgical benefits? if so when doing OUT of network services it's best to always send the carrier what's called a "pre-D" or "Pre-determination of benefits". This is where you send them the anticipated CPT code and the amount you will bill. The carrier will send back in writing a YES or a NO that the fee was within U&C. Carriers are NOT allowed to give out the dollar amount of U&C per procedure, for obvious reasons.

Again, you don't give enough detail with exact reason codes for denials or reductions. Also, if these plans are ERISA, there are ERISA appeal's process you can take, again depending on the denial or reduction.

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

PippiT

  • Newbie
  • *
  • Posts: 26
Re: Out Of Network Surgery Claims
« Reply #2 on: December 29, 2015, 11:39:48 AM »
I am sorry for the delay in my response. I really appreciate your response.

These are all surgery claims. Our ASC is out of network.

For the first two claims are with UHC provider services, trying to get them paid correctly that way.

We just kept getting a letter saying "based on our review this was processed correctly"

The billed amount for the first one is $31,100. Her out of network benefits are 80%. My provider expects to be paid 24,880 from UHC. They only paid $4,716.14. One rep said it is an MNRP plan and that the member's benefits steers how it will be paid. She said if we are non par, which we are, it is between us and the member, that it is basically member responsibility.

The second one the billed amount is $15,100. They paid nothing on it and put the allowed amount of $1,365.27 to the patient's deductible. Said the full amount is patient's responsibility even though they have 70% out of network benefits, so my provider expects $10,570 from UHC.

The 3rd one is from Cigna and I cannot get to the "right person". The billed amount is $21,500. They paid $3,070.98 the reason CO-45 charge exceeds contracted amount. we do not have a contract. It kept getting sent to Viant and Cigna says we have to appeal to viant or have the patient appeal on our behalf because the patient's employer elected a network savings plan. her out of network benefits are 80% so my provider expects $17,200 from Cigna.

Now I have a new one billed amount is $27,300. the ins paid $2,157.53. they say patient responsibility is $25,142.47. Her benefits are 50% out of network but my provider is telling me the billed amount has to be the allowed amount.

I am still learning the claims process, etc. but I have absolutely no clue how to handle these out of network claims. Is my provider right or wrong? He will not let me appeal. My predecessor said she just called until she "got the right person".

I hope I gave enough information. I have no idea what to do.

Michele

  • Global Moderator
  • Hero Member
  • *****
  • Posts: 4762
    • Solutions Medical Billing
Re: Out Of Network Surgery Claims
« Reply #3 on: December 29, 2015, 09:09:49 PM »
The insurance carrier is not going to make the billed amount the allowed amount.  They are going to use the UNC amount.  If the patient has out of network benefits of 70% or 80% or whatever they are going to pay that based on their UNC amount, not the billed amount.  The provider is incorrect in thinking that they will pay the % based on the billed amount. 
Sign Up for our FREE Medical Billing Newsletter
Get a 10% discount on Medical Billing Products by using Coupon Code: 10OFF
http://www.solutions-medical-billing.com

PippiT

  • Newbie
  • *
  • Posts: 26
Re: Out Of Network Surgery Claims
« Reply #4 on: January 07, 2016, 11:04:10 AM »
Michelle,

Thank you for taking the time to respond. I really appreciate it. I am at my wits end. He is expecting me to get the full allowed amount. I am new at this and I don't understand why he insists this is the case and how am I supposed to get what he wants? I can't even get the out of network benefit percentage that he wants.

I wish there was a book for dummies on this subject. There are two claims from a carrier that they paid the full amount. The lady who trained me called them "anomalies". Is there any resource out there for dealing with Insurance companies?

RichardP

  • Hero Member
  • *****
  • Posts: 688
Re: Out Of Network Surgery Claims
« Reply #5 on: January 07, 2016, 08:29:50 PM »
They ... put the allowed amount of $1,365.27 to the patient's deductible.  ... they have 70% out of network benefits, so my provider expects $10,570 from UHC.

It sounds like you and your client could benefit from a voice to voice conversation.  No carrier ever pays a percentage of what the provider bills.  The carrier always pays a percentage of their allowed amount.  The wording you are using tells me that either you have misunderstood what your client expects from you and the carrier(s), or your client is a new provider, unfamiliar with the ways of getting paid from insurance carriers.

Regardless of where the misunderstanding lies, the two of you need to come together on this understanding:  insurance carriers only ever pay a percentage of their allowed amount (in this case, $1,365.27).  And, yes - very often the carrier payment goes to the patient's deductible and not to the provider's pocket.  So, often the full amount must be collected from the patient.  Does your client expect you to verify the patient's ability to pay before he agrees to see them?  If not, then this is not so much your problem as it is your client's.

An ethical out-of-network provider will make certain the patient fully understands exactly what dollar amount s/he could be responsible for - for the services to be provided - before they are provided.  In this case, it sounds like the patient is responsible for the full charge (being out-of-network, your client is under no obligation to accept only 70% of what the patient's carrier will pay).

An out-of-network provider can charge their patients whatever they want to charge.  Collecting that money is another matter entirely.  Word-of-mouth can destroy a provider's reputation.  So your client needs to proceed carefully here.

PMRNC

  • Hero Member
  • *****
  • Posts: 4254
    • One Stop Resources & Networking for Medical Billers
Re: Out Of Network Surgery Claims
« Reply #6 on: January 08, 2016, 08:10:33 AM »
I agree with the others, the carrier for out of network is only going to base their % of payment on their U&C fees. BUT that is not to say you can't collect more with an appeal. The good news is that out of network U&C can be appealed, sometimes more gets paid, sometimes not. Your appeal has to be based on some research though with appealing U&C charges.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Michele

  • Global Moderator
  • Hero Member
  • *****
  • Posts: 4762
    • Solutions Medical Billing
Re: Out Of Network Surgery Claims
« Reply #7 on: January 08, 2016, 08:49:40 AM »
I agree with Linda & Richard.  The only addition I have is that the provider really doesn't know what he's collected in the past?  And is unrealistic in his expectations?  Being an out of network surgeon puts the majority of the burden of cost onto the patient.  Since he is out of network he has no contract with the insurance carrier which allows him to bill his full fee.  That does not in any way mean the insurance carrier will allow his full fee and process claims according to his full fee.  I used to work for an insurance carrier processing surgery claims.  Out of network or in network were always subject to RNC (or U&C - same thing).  We had some codes that were "hard data" meaning they had lots of data to back up their amount and they didn't budge, or "soft data" meaning they didn't have that much and they would negotiate the fee.  It was my job to call the provider and try to come to an agreement somewhere between our RNC amount and their fee. 
Sign Up for our FREE Medical Billing Newsletter
Get a 10% discount on Medical Billing Products by using Coupon Code: 10OFF
http://www.solutions-medical-billing.com

PippiT

  • Newbie
  • *
  • Posts: 26
Re: Out Of Network Surgery Claims
« Reply #8 on: January 08, 2016, 09:28:38 AM »
I have zero experience in medical billing. I got roped into the family business. I really like it but these out of networks are a pain. I really cannot wrap my brain around what exactly I am supposed to do. He won't let me appeal. I just have to keep running in circles.

The professionals are in network the ASC is out of network. Not sure if that makes any difference.

But yes, one example is he billed $27,300.00 the patient's plan in and out of network is 50%. $2,319.79 went to patients ded. and the plan paid $2,157.53. I have spoken with a supervisor and he said this is all the plan pays, we have a right to appeal but it is patient responsibility. My provider expects $13,650. He told me this is unacceptable.

So you can see my dilemma. It is impossible to get them to pay what he wants. He thinks because he is out of network that the billed amount is the allowed amount. What exactly I need is to be able to tell him what RichardP said above.

I asked for examples where they were able to get the out of network paid at what he wants an no one can produce them. There are two claims that a carrier paid the full billed amount. There was no calling on them, the claims were processed and paid timely. I have no idea why those two paid the billed amount but I guess that is why he thinks they should pay the full amount? I am not seasoned enough to know what I'm doing or how to explain to him that he is wrong.

PippiT

  • Newbie
  • *
  • Posts: 26
Re: Out Of Network Surgery Claims
« Reply #9 on: January 08, 2016, 09:37:46 AM »
An ethical out-of-network provider will make certain the patient fully understands exactly what dollar amount s/he could be responsible for - for the services to be provided - before they are provided.  In this case, it sounds like the patient is responsible for the full charge (being out-of-network, your client is under no obligation to accept only 70% of what the patient's carrier will pay).

An out-of-network provider can charge their patients whatever they want to charge.  Collecting that money is another matter entirely.  Word-of-mouth can destroy a provider's reputation.  So your client needs to proceed carefully here.

I completely agree with this. I have no idea what the doctor and the patient discuss, but I know to check with my insurance prior to any major surgery to see what kind of expenses I am responsible. What I don't understand is why do these out of network surgeries at the ASC when they should be done at the hospital. I'm not in his head so I can only surmise he has an unrealistic idea of how he should be paid.

The bottom line to him is that he does not have a contract and the billed amount is the allowed amount and that the insurance company needs to pay it. I've told him it is patient's responsibility per the ins. company and he says that is unacceptable. I feel like I've wasted a lot of time on these 4 claims.

rdmoore2003

  • Hero Member
  • *****
  • Posts: 625
  • Live Life and Love God
Re: Out Of Network Surgery Claims
« Reply #10 on: January 08, 2016, 09:58:47 AM »
I have to put my 2 cents in on this.   If the proof of past full payments cannot be produced, this is a RED FLAG and I do not believe this true unless their is some unethical practices going on.   Is this provider choosing to be out of network with all insurances or just these couple?    Do you call insurance companies prior to services to get the out of network benefits? 

With out of network companies, you have the right to have the patient to pay for services prior to the service.   You can then file the insurance and based on EOB, you may have to refund some moneys but at least you have your money up front.

The way I am understanding how this provider is, he/she has ABSOLUTELY no clue of what he/she is talking about.  My advise to you is to have a notebook and document EVERYTHING you do and what the provider says and does, (no patient information of course).  You could be liable for anything that comes down the line from your lady prior to you. 

Also, if providers that are out of network, got insurance payments in full, there would be no reason to have in network benefits/out of network benefits.   Common Sense people.
« Last Edit: January 08, 2016, 10:01:01 AM by rdmoore2003 »
Regina

PippiT

  • Newbie
  • *
  • Posts: 26
Re: Out Of Network Surgery Claims
« Reply #11 on: January 08, 2016, 11:46:19 AM »
I have to put my 2 cents in on this.   If the proof of past full payments cannot be produced, this is a RED FLAG and I do not believe this true unless their is some unethical practices going on.   Is this provider choosing to be out of network with all insurances or just these couple?    Do you call insurance companies prior to services to get the out of network benefits? 

With out of network companies, you have the right to have the patient to pay for services prior to the service.   You can then file the insurance and based on EOB, you may have to refund some moneys but at least you have your money up front.

The way I am understanding how this provider is, he/she has ABSOLUTELY no clue of what he/she is talking about.  My advise to you is to have a notebook and document EVERYTHING you do and what the provider says and does, (no patient information of course).  You could be liable for anything that comes down the line from your lady prior to you. 

Also, if providers that are out of network, got insurance payments in full, there would be no reason to have in network benefits/out of network benefits.   Common Sense people.

EXACTLY on the last line! That is my take on it. We are in network for a couple of insurances. I do not know why they are not in network for all. I have started wondering if he was using my inexperience to try to argue more.

I do call the patients insurance to verify benefits and get in and out of network surgery benefits. If surgery is scheduled I also get pre-auth etc. I don't believe anything unethical is going on. He is very good at detailing everything he does and bills. I just think somewhere he got in his head that the billed amount should be the allowed amount. They've been in business for a long time so I am the only one with very little knowledge.

The notebook is a good idea. Thank you for your two cents!!

PMRNC

  • Hero Member
  • *****
  • Posts: 4254
    • One Stop Resources & Networking for Medical Billers
Re: Out Of Network Surgery Claims
« Reply #12 on: January 08, 2016, 02:41:55 PM »
Quote
He won't let me appeal. I just have to keep running in circles.

Ok, so you are DONE.. he won't let you appeal, won't let you bill patient. There's nothing further that can be done. Have you thought about going to them and telling them it's more beneficial to be in-network? With an ASC, you stand a much better chance of higher reimbursement from the insurance company than asking the patient for THOUSANDS of dollars up front.

On a side note.. you said the providers were par the ASC is not.. are you guys making sure the providers are informing patients of this? Why are IN network providers even referring to an OUT of network ASC?   No one has asked that yet.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

kristin

  • Sr. Member
  • ****
  • Posts: 493
Re: Out Of Network Surgery Claims
« Reply #13 on: January 08, 2016, 11:59:41 PM »
I wrote a long reply to this post, and ended up deleting it accidentally. I see that many of the things I addressed in my deleted post have been addressed by others. Such as, if a provider thinks the billed amount is the allowed amount, why would any provider be in network, and why are patients being treated at an out of network ASC if the surgeon is in network and do the patients know this ahead of time, and finally, why does the provider think what they billed should be the allowed amount, and who gave them that information, which is incorrect?

Bottom line,the OP is between a rock and hard place, which is even worse when the OP is not an experienced biller. It looks like a few claims were processed incorrectly at full billed amounts, leading the provider to think that all claims should be processed that way, and when the provider says no appeals can be done, nor can the patient be billed, what is left as a recourse?

To the OP, my suggestion is to go to to the websites of each insurance company the provider is questioning payment on, and print off their policy on out of network benefits. Most, if not all, will clearly state how they will pay to OON providers. Which generally includes UNC rates, how they are applied, etc.
« Last Edit: January 09, 2016, 01:51:36 AM by kristin »

Questhrr.com

  • Newbie
  • *
  • Posts: 17
Re: Out Of Network Surgery Claims
« Reply #14 on: January 25, 2016, 09:11:45 AM »
Hello PipiT,

I can concur that everything people are saying here is true.  Howbeit, I also am fully aware of tactics used by UHC and Viant, whereas, they are not fully paying what the members' policy requires.

It is true that this provider seems to have unrealistic expectations, however, there may be more reimbursements which he can recover.  If you wish to point him to my services, you can direct him to my website at www.questhrr.com.

Thanks,

Kevin