Inconsistent OON Reimbursement Rates (same patient, different claims)


Islip, NY
Best answers
Hello all. I work for a bariatric surgeon. Recently we have noticed payers like Aetna and UHC reimbursing us at wildly different rates (we are out of network with them). For example, a patient will have an upper endoscopy that is paid almost in full ($11K). The EOB states the reimbursement is based on Multiplan's contracted rate. I should note that no negotiation with Multiplan was made. Then when the patient has a laparoscopic sleeve gastrectomy, the insurance reimburses us what EOB states is 140% of Medicare's rate (only $1K). My understanding was that the reimbursement rate is determined by the plan that the patient has. How can it be that the reimbursement is different for the same patient with the same insurance plan across all treatment? This doesn't seem right. Has anyone else experienced this? If so, any suggestions on how to fight it?
Thanks so much.


True Blue
Clovis, CA
Best answers
When you are out of network, they can use any means they want to price the claim. But that shouldn't matter to you, as you are not bound by those prices. They can use U&C, they can use Medicare, they can make up stories about networks that you are not part of (all of which I have seen). I saw one insurance use U&C as well as a non-existent network on two different line items on the same claim. This is the patient's fight, not yours.

What you may want to do, is set your own "Time of Service discount". This is a percentage off your regular billed amounts that you are willing to accept for cash pay or out of network patients, as long as the patient pays their estimated portion on or before the date of service. Like this:

Upper Endoscopy billed at $15,000.

Time of service discount is 20%. This means you expect to be paid $12,000 from all sources.

Now, if in your experience, Patient A's insurance pays around $10,000, then the patient would pay $2,000 on/before the procedure. This is a good faith estimate. Then if the insurance pays less than $10,000, you bill the patient for the rest. If the insurance pays more than $10,000, you refund the patient the difference. Like this, two patients, same insurance:

Patient A paid $2,000; Insurance paid $9,500; bill patient for $500.
Patient B paid $2,000; Insurance paid $11,000; refund patient $1,000.

If the patient pays nothing on/before the procedure, there is no discount and you collect your full charges from all sources.