6 Key Areas to Succeed With Out-of-Network Reimbursements
At the 19th Annual Ambulatory Surgery Centers Conference in Chicago on Oct. 26, Lisa Rock, president of National Medical Billing Services, discussed six areas ASCs must address in order to succeed with out-of-network billing.
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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