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Is Your ASC Missing Out on Making Money from Out-of-Network? Thoughts From John Bartos of Collect Rx

An out-of-network reimbursement strategy can be profitable for surgery centers, despite pressure from payors to move in-network. The important thing is making sure your processes are set up to collect in full on out-of-network procedures, rather than failing to appeal and leaving deserved money on the table. John Bartos of Collect Rx discusses a few mistakes surgery centers can avoid to make sure their out-of-network strategy works.

1. "Defaulting" to a strategy of 100 percent in-network participation.
Mr. Bartos says he commonly sees providers "defaulting" to a strategy of 100 percent in-network participation, and thus failing to take advantage of the opportunities to obtain higher out-of-network reimbursements. True, out-of-network does not work in every market — but Mr. Bartos says "the reality is that in most geographies, providers can increase revenue by having a portion of their revenue come from out-of-network patients."

He says this requires an analysis of each of the surgery center's payors. Compare in-network and out-of-network reimbursement levels for your most common procedures on a payor-by-payor basis, and determine which contracts should be cancelled to reap a higher return.

"In addition, providers need to understand both the local payor and employer mix, as well as their relative market share compared to other providers." He says if providers are prudent in picking the payors with which they pursue out-of-network, they should be able to maximize total revenue and profits.

2. Failing to maximize reimbursement with an out-of-network strategy. Mr. Bartos says when providers do decide to pursue an out-of-network strategy, they often fail to take the necessary steps to maximize their out-of-network reimbursement. "We see providers accept reimbursement levels that are perhaps only slightly above their in-network or Medicare or Medicaid rates," he says. "The payors, knowing that providers won't push for more, will often under-pay those claims."

He says this strategy requires staff members who are dedicated to negotiating out-of-network settlements on individual bills and effectively appealing claims. If your surgery center does not have staff members experienced with out-of-network bills, you might consider hiring a third party to handle this side of your reimbursement. "The provider [also] needs to have supporting data to be effective in negotiating individual bills," Mr. Bartos says. "For example, the provider must have the ability to identify the inconsistencies between the EOB and the remittance advice and be able to decipher the actual language."

Providers must also follow a rigorous appeals process if reimbursement is unsatisfactory. The process includes, for example, elements like:

• Creating a well-drafted assignment of benefits that – (1) assigns the surgery center all rights under the insurance policy (including the right to appeal and the right to receive relevant documentation); (2) refers to the provider as the patient's authorized representative, and (3) references ERISA and a full and fair review of claims.

• Documenting all calls with the payor (benefits, pre-authorization, etc.). "Make sure that both parties understand what was said and that the surgery center has a record of what was said," Mr. Bartos says. He says in many cases, surgery centers never call the payor to inquire about insufficient reimbursement.

•  Recording the reference numbers of all payor calls. Mr. Bartos says when a surgery center calls a payor, the payor assigns a reference number to that call. The staff member should document the reference number, in case there is a dispute later over what was said. "If the provider can't give the reference number, the payor can say, 'We never had that call,'" he says.

He says while the appeals process can be time-consuming, it significantly increases collections in the long-term. "It can take months to reach a settlement on an appeals case, and that's why it's important to have a process in place," he says. "A number of ASCs don't appeal because they don't have resources to do so. It's time-consuming but it is definitely fruitful."

Learn more about Collect Rx.

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