6 Key Areas to Succeed With Out-of-Network Reimbursements
1. Front-end processes. Tidying up the front-end process can make a significant difference. In order for ASCs to stay out of network, ASCs must consider insurance verification, networks, online access and authorization requirements.
2. Notification. ASCs can reduce risks with a disclaimer or notification on the claim. These may include, "We intend to honor in-network deductibles and co-pays."
3. Out-of-network adjustments. ASCs must factor in or consider out of network adjustments for deductibles, co-insurance and co-pays.
4. Carrier. Keep an eye on what carriers are doing and changes to out-of-network payment trends and recent case laws.
5. Back-end processes. Trained payment posters are key to flagging low payments and alerting the accounts receivable team. Establish definitions for "low payments," strengthen your position during back-end negotiations for underpaid claims and be mindful of patient authorizations for appeals.
6. Managed care contracts. Ensure you are working with a managed care company and you understand reimbursement methodology, rates and implants, EDI and EFT requirements, Most Favored Nations clause and silent PPO language, among other critical factors.
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