Author Topic: Out of network allowable  (Read 3894 times)

Crush3174

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Out of network allowable
« on: October 09, 2014, 03:34:47 PM »
Hello! This is my first post and I'm hoping someone can answer this for me. I have submitted a DME claim for a client who is out of network. Multiplan is trying to push the doctor to sign off on a discounted allowable. I know the billed charges on the DME item are less than the U&C the insurance is currently paying in that area. The insurance company confirmed if no agreement can be made than they will process the claim at MRC2 which is 300% of Medicare allowable. Medicare allowable for this region is $1340.50. Can someone tell me what the allowable will be? Multiplan is saying if we don't sign then the allowable will be less than $800.00.

barb2512

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Re: Out of network allowable
« Reply #1 on: October 09, 2014, 03:46:54 PM »
When working with murtiplan I have found that if the doctor does not sign the document then they are actually reimbursed more than the multiplan document promises. I have found that the leverage they are trying to use is telling providers that they will be reimbursed quicker with the contract than without.

I know this doesn't answer your question.  ;)

Barbara

PMRNC

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Re: Out of network allowable
« Reply #2 on: October 09, 2014, 04:43:33 PM »
Quote
I know the billed charges on the DME item are less than the U&C the insurance is currently paying in that area. The insurance company confirmed if no agreement can be made than they will process the claim at MRC2 which is 300% of Medicare allowable. Medicare allowable for this region is $1340.50. Can someone tell me what the allowable will be? Multiplan is saying if we don't sign then the allowable will be less than $800.00.

If you don't sign up your fee is subject to U&C however amounts over U&C are collectable from the patient. Can you accept a participating plan discount on a per claim basis? that will allow you to collect up to the allowable but you won't be able to collect anything more from the patient outside any coinsurance/copay
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