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Negotiation offers, appealing underpayments & more: 5 FAQs on out-of-network collections

With payers employing a variety of tactics to minimize reimbursement, the key to successful out-of-network negotiations is persistence, according to CollectRx Executive Vice President Richa Singh.

At Becker's ASC 25th Annual Meeting: The Business and Operations of ASCs, Oct. 18-20 in Chicago, Ms. Singh discussed negotiation strategies, appealing underpayments and third-party rental network agreements.

Here are Ms. Singh's answers to five frequently asked questions:

Note: Responses have been edited for length, style and clarity.

1. What is the No. 1 key to successful out-of-network negotiations? Persistence. It's basically a battle of the wills — it's who's going to walk away first. The insurance companies and the vendors, they're putting up every single roadblock that they can. Their goal, their sole aim is to get you to walk away. On the negotiations [and] the settlement offers that you get, one of their tactics is to keep sending you [the same] number. Keep getting back to them on all of it. What they're betting on is that you're just going to stop.

2. Is it worth the trouble negotiating if we don't see a lot of out-of-network volume? You should still be negotiating all of them [because] the margin to negotiate is so great. [Frequently,] they'll first pay you 20 percent, 30 percent and you have an opportunity to get up to 80 percent, 90 percent — if not on that one bill, over time. Even if you have five bills and you can get an extra $2,000 on a bill, that's $10,000 in that month — that's $120 grand in the year — and that's just from negotiating five cases. So, even if you have low volume, still do it. Any money is good money.

3. Won't negotiating aggressively ruin my relationship with these vendors? You have to remember this is a business for them and they're trying to make money off you. They're using different tactics, and one of those tactics is to build a relationship, build rapport with you so they can negotiate. … One of our negotiators came from working on the insurance side, and she used to negotiate against this ASC we had approached once. The ASC told us they had a great relationship. We asked her, 'What did you do?' She said, 'Well, I found out that she liked shoes, so I talked to her about shoes for the first couple minutes, and then at end I get an 80 percent discount out of them.' That means that business office manager got reimbursed at 20 percent of bill charges. There's no relationship I ever want where they're taking 80 percent of my money.

4. What's the best way to successfully appeal underpaid bills? Resources is the first one. Especially if you're close to 100 percent of out-of-network, you can't have somebody that's part-time appealing and part-time scheduling. You need somebody that's spending time on this; appeals can take anywhere from one to six months to resolve. A lot of our appeals are resolved within three months, but I was just looking at a case that we're on our ninth month on. It's a very large bill.

5. What are third-party rental network agreements? They're also called silent PPOs. A silent PPO or third-party rental agreement is not a contract directly with the insurance company, this is a contract with a middleman. They're in the middle of the provider and the insurance company, and their purpose is to save the insurance company money, not you. They sound easy, but they can be very detrimental.

More articles on coding, billing and collections:
CMS revises Local Coverage Determinations chapter in Medicare Program Integrity Manual — Here's what you should know
Ex-physician found guilty of conspiracy, healthcare fraud: 5 insights
ASC patient financial responsibility: Analyzing the statistics

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