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Out Of Network Surgery Claims

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PippiT:
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:
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.

PippiT:
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:
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. 

PippiT:
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?

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