Common Misconceptions About Out-of-Network Reimbursement
1. Days of out-of-network are over. Mr. Bartos said this prediction has been echoed throughout the last 15 years, and it remains today for a variety of reasons. Realistically, there are still about $60 billion annually in OON claims in the market. Although they vary among centers and certain regions, Mr. Bartos also said OON payments are higher in many areas.
"At the end of the day, the market force driving OON" is a simple one, said Mr. Bartos: People will still want to see OON providers. "It's just a market supply and demand factor," he said. There will be more insured with OON benefits in coming years under the Patient Protection and Affordable Care Act, but patients may seek a clinical expertise or certain provider that is not in-network under the exchange or under their plan.
2. Being 100 percent in-network maximizes reimbursements. Mr. Bartos said he sees surgery centers all around the country grapple with the issue of whether to be in-network or OON. What he often sees work is a "hybrid approach" in which a portion of the ASC's business is in-network and another portion is OON.
When deciding which contracts to keep and which to cancel, ASCs should look at the following factors:
- Local payer mix
- Local employer mix
- Comparable reimbursement levels for most common procedures
- Relative market share
What do you do after this analysis? "Our recommendation is that you don't go out and cancel all of your contracts," said Mr. Bartos. "What we recommend is you take a dip-your-toe in the water approach."
To do this, ASCs can focus on a smaller payer in their book of business. Find a contract in which reimbursement levels might be better if OON. ASCs can cancel that one contract and keep an eye on their OON reimbursement levels for the next three to four months. "You'll have a good picture by that time if in-network or OON was better," says Mr. Bartos. There's also less risk this way, as most providers should be able to reenter contracts if OON does not work for them.
3. We've got it covered. This might be the biggest myth, said Mr. Bartos. "We talk to providers all the time about OON and they say, 'We've got it covered. There's nothing more to talk about here.'" The reality is there are still large opportunities for many OON providers to do it better," said Mr. Bartos. "You don't know you're losing a lot of money by not doing more on these bills.
Teams should examine the following things if they think they "have it covered."
- Expertise. One example is staffs' ability to translate an explanation of benefits.
- Assignment of benefits. "Make sure you have an explanation of benefits that is very explicit and specific," said Mr. Bartos. The EOB should also assign rights to documentation and appeal.
- Documentation of all calls. It's extremely important for staff to document calls with payers. Take detailed notes.
- Recording of reference numbers. Write down reference numbers for calls with payers since they are all recorded. "Having that information at your fingertips is very, very powerful," said Mr. Bartos.
More Articles on Out-of-Network Reimbursement:The Future of Out-of-Network Reimbursement for ASCs: 4 Thoughts From Industry Experts
5 Reasons ASC Providers Should Remain Out-of-Network
How to Successfully Handle Out-of-Network Contracts in ASCs
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