Appeal techniques for OON claims

Billing500

Networker
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One of our providers recently decided to go out-of-network with major insurance companies.
I'm looking for some tips on what to include in our appeal letters to these payers for increased reimbursement. We are mentioning:
  • FAIR Health rates for our geographical area
  • Relevant aspects of the economics of the medical provider's practice (location, costs, etc)
  • Provider's training, qualifications, and length of time in practice

Any added suggestions to strengthen our appeal would be appreciated. Our patients are choosing to come to our office vs. another in-network provider. So, the whole song and dance about the patient not having a choice is not applicable here.

Thank you!
 

CodingKing

True Blue
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Since its a choice vs forced, not much you can do with most payers since you have pretty much no leverage. With the payers I've worked for there is always a set reimbursement method w/ no negotiation unless the services are not available in plan.
 

Cheezum51

Expert
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In general, OON reimbursements tend to be lower than those for in network providers. If your provider is agreeing to accept assignment for the OON claims as payment in full, then he/she shouldn't really expect the insurers to pay more based upon what you've outlined for your appeals.

In reality, as far as the insurance companies are concerned, your provider is saving them money they'd have to pay to an in network provider and that's going to their bottom line profits.

Tom Cheezum, O.D., CPC
 
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