Billing > Facility Billing

Negotiation for out of network facility claim.

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HavenBilling:
Have you ever requested a single case agreement or letter of agreement. We do this quite often with out of network members because there is not another facility close enough to them. I don’t know if that’s a possibility for you, but we do a lot of LOAs and negotiate our rate up front and sign an agreement for the member to use their in network benefits.

PMRNC:
A single case agreement is good idea..works sort of like a pre-determination of benefits. You send them the CPT codes and they tell you yes or no they are within U&C. They won't tell you the U&C amount for this type of arrangement. I would def get any agreement in writing. They will not just arbitrarily give you a "fee schedule amount" because they can't. They don't because if they come back with a price that's higher than your actual fee (I know it's not likely but that's their preception) you will bill that amount and that wouldn' t be right. You need to let them know the fees that you charge that is not going to be unavaidable if you want to negotiate. Not all carriers will negotiate out of network rates and more times the patient has better success in getting the approval first to go out of network. If they don't or won't negotiate than you can have patient do a hardship and write off the amounts over U&C. As long as this is not done routinely and on case by case basis following hardship and documentation this would be perfectly acceptable to do.

Michele:
We have seen these single case agreements in areas where there are no in network providers.  The insurance carrier will give auth and approve a fee schedule amount on a per case agreement for a provider who is not in network if they cannot find an in network provider in the area that can take the patient.

HPATEL:
Yes, That is what I had an understanding. They only give out single case agreements in areas where there are no IN-Network providers.  So far I figured out for Aetna and BCBS and United. But United is dicey. since they change their policy in the beginning of 2018.

bvikash:
Actually it is very hard to negotiate claims for out of networks, however we can still refer fair health prices as many company follow it like Cigna. We can also refer our old claims data and let the insurance company know that what they were paying previously and they cannot pay less. We can also refer to Mental Health Parity and Addiction Equity Act (MHPAEA) LAW.

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