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4 tips to maximize out-of-network reimbursement

Patients have been increasingly seeking out-of-network care, and this trend is expected to continue, according to John Bartos, JD, CEO of CollectRx.

As consumers become increasingly informed and discerning healthcare shoppers, the demand for choice will continue to drive out-of-network activity. People want insurance policies with OON benefits, and insurance companies will need to meet these demands, according to Mr. Bartos.

OON reimbursement tends to be higher than in-network reimbursement, so payers use different strategies to discourage it, including bill reduction tactics, limits on benefits policies and third-party rental agreements that lower reimbursement.

"There aren't a lot of opportunities to increase [ASCs'] reimbursements," Mr. Bartos said at the Becker's ASC Review 13th Annual Spine, Orthopedic and Pain Management-Driven ASC Conference in Chicago. "Your in-network contracts are what they are — there's very little opportunity to increase those rates. Medicare and Medicaid is what it is. Out-of-network represents the last great opportunity for many providers to increase their reimbursement on out-of-network bills."

According to Mr. Bartos, seeking higher reimbursement for out-of-network care must be a part of every provider's revenue enhancement strategy.

Consider the following four tips to maximize reimbursement.

1. Commit to the goal of improving reimbursement rates for OON care. "You need to invest in order to make this happen. You can't take this lightly; you can't take this as a side project. You have to decide as an entity that success on OON reimbursement is important to what you're trying to accomplish and you have to devote resources to making that happen," said Mr. Bartos.

2. Adopt a hybrid approach. According to Mr. Bartos, ASCs should determine which payers to sign in-network and out-of-network contracts with on a payer-by-payer basis, and this will depend on their particular region. With this approach, ASCs can assess their payer mix, employer mix, relative market share and ability to contract for OON care.

3. Don't just dive in. For ASCs that have not previously signed OON contracts, Mr. Bartos recommends a "dip your toe in the water" approach, in which an ASC identifies just one or two payers that represent a small volume of their business to do a test run of an OON contract. After this trial period, the organization can identify the tactics they need to get the most out of OON reimbursements and then decide if it makes more sense to stay OON with them or go back in-network.

4. Determine if in-house or outsourcing is right for your ASC. Increasing OON reimbursement is labor-intensive. It requires a significant amount of time and persistence. "ASC staffs are already juggling a lot of things. They must be able to spend the time they need to in order to get higher reimbursements on these claims," said Mr. Bartos.

If ASCs don't have the proper resources and expertise in-house, they can outsource the responsibilities to a qualified group of experts.

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