Although out-of-network billing requires more work than in-network contracting, health systems shouldn't abandon it because the rewards are lucrative.
CollectRx Executive Vice President Richa Singh answered a plethora of frequently asked questions at Becker's 4th Annual Health IT + Revenue Cycle Conference, Sept. 20 in Chicago.
On how to be successful with out-of-network negotiations: "One of the things we do is keep track of insurance policies. The reason we do this is -- surprise-surprise – these insurance companies aren't always very forthcoming whenever they're in negotiations with you. They may tell you it's 110 percent of Medicare that's on the proposal, but the policy says it's based off of usual and customary. You have to make sure you have the right policy or the right definition of how that bill is supposed to be reimbursed.
"Another part of our database is we keep track of all the data we've negotiated. This is another tip. Keeping track of data is crucial for your negotiations because [you have to] back up your arguments on what you think you should be reimbursed. We keep track of all of our past negotiations. … If you can keep all that data organized, it'll definitely help in your negotiation."
On why you should negotiate out-of-network, despite the low volume: "We hear from providers that have 2 percent or 5 percent out-of-network that don't do anything with it because [they say,] 'It's not a big part of our revenue.' The thing with out-of-network is, in a perfect world, they're supposed to reimburse you at 100 percent of charges. It just doesn't happen. So, if they're reimbursing you at 20, 30, 40 percent, you do have the opportunity to get to that 100 percent. Some negotiations even get to 80 percent or 90 percent. So, if you're able to quadruple that one bill what you were initially paid, even on that lower volume, it's all going to add up. Do negotiate and engage in negotiations when you see out-of-network. If you think about it, your in-network rates you can't change, Medicare and Medicaid? You can't do anything about [those], but out-of-network represents a great opportunity to increase reimbursement."
On appealing underpaid bills: "First off, you need to have the resources for it. If you have a decent amount of out-of-network or a major payer you're out-of-network with, you need to have dedicated people. If they're also doing other things in collections and appeals, they're not spending enough time on it. It takes a lot of time. Any of these appeals can take from one to six months. You have to research, you need to [make] multiple calls, you have to write letters – sometimes you have to take different avenues.
"You need dedicated resources for these appeal processes. You have to have a method to your madness. Have different avenues you can go.If it didn't work through the payer, is there somebody else you can talk to?
"[Have] persistence, of course. Make sure you're following up on all your appeals. They're going to give you the runaround."