Persistence is key for health systems negotiating out-of-network payments. Collect Rx is the only company in the nation devoted to negotiating out-of-network bills for healthcare providers.
Collect Rx Executive Vice President of Sales Richa Singh answered frequently asked questions about out-of-network payments April 12 at Becker's Hospital Review 9th Annual Conference in Chicago. Providers bill out-of-network rates when they don't have an in-network contracted rate for reimbursements with the patient's insurance company. When payers receive an out-of-network bill, they typically send it to a third party vendor employed to reduce payments through bill minimization tactics. The vendor evaluates the bill and chooses to pay less than the charge amount; to deny the claim; or to negotiate with the provider before payment.
"We call out-of-network the Wild West," Ms. Singh said. Health systems can benefit from being out-of-network, since properly negotiated out-of-network reimbursement rates are a lot higher than in-network rates as well as Medicare and Medicaid.
However, Ms. Singh cautioned healthcare providers to be wary of third-party rental agreements; she explained these so-called "silent PPOs" are an insurance company tactic to lower reimbursements by accessing the discounted rates of another insurer, typically without the provider's knowledge. So why do so many providers contract with silent PPOs? "It's easy," Ms. Singh said. But ease of use should not be a provider's only consideration.
There are opportunities for healthcare providers to develop an out-of-network strategy that will maximize reimbursement on those cases. The best way to negotiate with payers is over the phone, because the element of talk is crucial to presenting the data. "Call everyday, write letters everyday if you have to," she said. "Persistence pays off."
Ms. Singh told providers to do an audit of their explanation of benefits to track whether their third-party rental agreements are being applied correctly. TPA vendors are allowed to give providers less than a day to negotiate, and once a discount is agreed upon, the payer can change their mind. "You may wonder if negotiating aggressively will ruin your relationship with these vendors," Ms. Singh said. "Remember that they are not your friend."
Ms. Singh also advised against signing up with a TPA's web portal because the computerized system automates single case rate agreements, making it harder to negotiate in the future.
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