Cavalier40
Guest
I was not sure whether to post this here or in the payer section, but since I think this is targeting MH/SA facilities, I will post here.
As an out of network Cigna provider, I would generally negotiate facility based SA claims with Multiplan. I would get the same discounted rate across the board since I have been working with Multiplan for so long. However Cigna is now putting a restriction on the repricing of these claims called MRC2. I am being told they are locking in prices based on Medicare allowed amounts. At first it only effected professional claims which made sense because there was a fee schedule to refer to, However now they are saying facility claims are also being effected by MRC2. This confuses me because there is no Medicare allowed based on revenue code. (Or are there? If so can someone point me to the fee schedule?) They are forcing me into a price that is less than half of what I have been negotiating for 2 years now and if I do not accept their repricing amount, they will only reimburse a fraction of the Medicare allowed (for example I was told that Cigna would pay $407 for 5 days of Residential treatment if I did not accept their repricing, out average expected is over $900 per day)
To be honest I feel bullied and strong armed, however I think they are calling providers bluff in not balance billing the patient. Since the business model for most treatment centers is to not count on patient responsibility and I know that there are many providers who are not in compliance with anti-kickback laws it makes sense for the payers, but it still feels wrong.
I am wondering if anyone has had success with post payment pricing appeals or have other success when getting the patient involved? Any tips on how to counter this would help greatly.
As an out of network Cigna provider, I would generally negotiate facility based SA claims with Multiplan. I would get the same discounted rate across the board since I have been working with Multiplan for so long. However Cigna is now putting a restriction on the repricing of these claims called MRC2. I am being told they are locking in prices based on Medicare allowed amounts. At first it only effected professional claims which made sense because there was a fee schedule to refer to, However now they are saying facility claims are also being effected by MRC2. This confuses me because there is no Medicare allowed based on revenue code. (Or are there? If so can someone point me to the fee schedule?) They are forcing me into a price that is less than half of what I have been negotiating for 2 years now and if I do not accept their repricing amount, they will only reimburse a fraction of the Medicare allowed (for example I was told that Cigna would pay $407 for 5 days of Residential treatment if I did not accept their repricing, out average expected is over $900 per day)
To be honest I feel bullied and strong armed, however I think they are calling providers bluff in not balance billing the patient. Since the business model for most treatment centers is to not count on patient responsibility and I know that there are many providers who are not in compliance with anti-kickback laws it makes sense for the payers, but it still feels wrong.
I am wondering if anyone has had success with post payment pricing appeals or have other success when getting the patient involved? Any tips on how to counter this would help greatly.