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ques re:3rd party repricer Multiplan and Data ISight tactic

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Based on these out of network problems in billing. I have a question for you all. Years ago out of network was the way to go, Many of my clients liked to be out of network. Not so sure any more. I do know that in my experience out of network providers in regards to appeals I get no help from the Insurance Carriers rep. Can any of you share if you believe,  in or out of network is best.

There is no easy answer to this question, as it depends on the mentality of each provider. Some don't want to  play the "insurance game" and choose to be OON, others want to get as many patients as they can, and contract with every insurance that they can. Here is what I have found over the years...most PATIENTS want to know that they are seeing a contracted provider with their insurance. And you have to be honest with them when they call, and ask if your office/provider is in network. If your provider isn't, you will lose patients, because they will say thanks, but no thanks, and move on to a provider who is is contracted with their plan.

Right now, I am dealing with contracting a provider with all insurances our office is contracted with. Unfortunately, there is one insurance in our area that is no longer accepting providers within our specialty. (Humana, Podiatry). So while two of the docs in our practice are grandfathered in with Humana, the newest one can't get into Humana(which is fine by me, I HATE Humana). So when a patient with Humana calls, we have to explain that while they can schedule with two of our providers, and that will be a few weeks for an appointment, they can also schedule with the new provider immediately, but it will be out of network. 9 times out of 10, the patient says they will call around for another appointment, that will be sooner, with an in-network provider. And I completely understand why. Who wants to see an OON provider when they can see one who is in-network?

There are situations where not being contracted doesn't matter to potential patients, and not being contracted doesn't matter to the provider. But they are not the norm. It depends on the provider specialty/financial situation/length of practice, and the patient demographic in your area.

Actually there are a couple of EASY solutions,  tell third party you don't negotiate like Michele says, those repricing companies are nothing more than a carrot dangling on a stick. The min you sign the "deal" you lose your ability to appeal so I don't understand why providers even take those deals to begin with.

For non ERISA and out of network, this is really easy. With ERISA the insured is entitled to certain details about how a claim was paid or not, an adverse benefit under ERISA is any denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit. That gives the beneficiary a chance to appeal the payment reduction and request ALL documents, certifications and names of all those who made the determination and details on how the benefit was reduced and why. A provider can do this on behalf of a patient but they need the proper ARF which gives the provider the right to act on behalf as a representative of the member/patient. A valid assignment of benefits is not sufficient so you will need the patient to sign an ARF. You'll also want their benefit plan (SPD) which details the appeal process which must be followed to a "T" in most cases you are NOT appealing to the carrier but possibly to an executive board, the employer or fiduciary, etc. When you put your appeal letter to work and it is received, MOST times the carrier will reverse the denial or increase the benefit payment (This type of appeal always works for me on U&C reductions) because they will fail to meet the appeal rights and grant the documentation the member is entitled to.

With Aetna you just have to watch your Medicare replacement plans, those are not ERISA but they also do not have to play by all the rules of Medicare.

Just FYI:  more than 85% of all claims the average biller touches, are ERISA. Knowing that up front, obtaining the proper ARF and benefit verification allows you to get ahead of situations like this.


--- Quote from: Debw00 on August 29, 2019, 07:17:49 AM ---Please -any help with fighting this Aetna /Data isight is needed.  Called a lawyer versed in these matters-she said its possible Aetna would retaliate against my practice.  This must be fought by an association or legally thru govt channels.   I don't understand why the New york Chiropractic Association or Counsel has not brought action yet.....

If anyone has any any info please advise

--- End quote ---

Hi Deb - interested in the topic. Did you find out if Aetna can retaliate? Does this still happen to you?

From what I have found so far, you are not obliged to accept a lower payment offered via Multiplan or Data iSight. Your benefit must be just getting your money faster (so useful for cash management) but you accept a lower amount. Alternatively, you can reject and receive your normal payment just it could take longer. So my understanding is that the benefit to physicians is just time (and well the cost associated with that).

Does the above sound right?

Thank you!


--- Quote from: margarita0930 on July 23, 2019, 08:43:14 PM ---From my experience, you can negotiate reimbursement for OON PT claims with DataIsight.  For example: Aetna/Cigna. Billed amount $1,350/$1100 for I/E and $880 for F/U- they automatically pay around $130/$150 per visit. When you call DataIsight you can open a case for negotiation and request 40% off of the billed amount. We in NYC usually get around $500-$380 per visit. Not sure what the OON reimbursement is in other states. Hope this info helps.

--- End quote ---

Hi Margarita,

I am a little confused - are you a health service provider or a physician? I thought health providers would prefer or would like to negotiate for a higher reimbursement?! How does it make sense to negotiate a lower payment? Or are you speaking as a patient?

Thank you!


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