Out of Network Appeals for ERISA plans

Billing500

Networker
Messages
42
Best answers
0
Does anyone have an effective appeal letter which addresses inadequate reimbursement for OON self-funded plans? We have a solid assignment of benefits form, however, we could use some direction with the context of our actual appeal. I understand we have quite a bit of rights under ERISA. If the claim isn't paid/allowed in full, the claim is effectively considered a denied claim. Would love to collaborate with other offices.

Thanks!
 

CodingKing

True Blue
Messages
3,952
Best answers
0
I'm curious where under ERISA you believe mandates a specific allowed. The amount over allowed belongs to the patient for OON.
 

avon4117

Guru
Messages
246
Location
FLINT
Best answers
0
I thought out of network charges fall under benefits and patient is liable. Why is the provider appealing?
 

Cavalier40

Guest
Messages
139
Location
Stuart, FL Sailfish Chapter
Best answers
0
I work 100% out of network.

On the verification side, you should ask if OON pricing is done based off the Usual and Customary Rate (UCR), an Out of Network Allowed, or a % of the CMS rate. For BCBS plans, ask if the pricing is done by the home plan or local. If it is priced by the local, then you are stuck with whatever pricing method they use.

If the pricing is based on an allowed, or a % of the CMS rate, you are pretty much stuck with that reimbursement. You can try an appeal, but they will have pretty consistent price table to work off of.

If the pricing is based off the UCR, then a few things can happen.
1. The claim will be repriced by a 3rd party company such as Multiplan or HRGI. There might be restrictions like MNRP for UHC, or MRC1 and MRC2 for Cigna. Sometimes you can negotiate for a % of the billed amount. You can even create global agreements for a fixed amount, or create a network contract with Multiplan that will keep you out of network with the insurance, but keep pricing consistent.
2. The claim will go through a different 3rd party company that will go through a regional price table. Viant and Data I-sight are such companies. You are usually stuck with these repricings.
3. If the claim is Aetna, it may be repriced through their in house company (Global Claims Service) When they are priced by Global, this is the only method I know that allows the facilities advocate for the patient. Not all claims are repriced by Global. There should be a 1-800 number on the EOB to contact them and they will send you a pre-made spreadsheet to send back the claims.

If you are going to send a pricing appeal, You would only be able to do that if the pricing is based off the UCR. I would try to fight for some sort of aggregate amount and not try to gouge. (I wouldn't ask for $1200 for a procedure in which the CMS rate is $40)

Also note that if it is a Union Based plan, they are exempt from most regulations created by the ACA that other self funded plans would be bound to. There is very little chance that you would get anywhere with those type of policies.

I hope this helps
 
Last edited:

Cavalier40

Guest
Messages
139
Location
Stuart, FL Sailfish Chapter
Best answers
0
Its a business decision to stay out of network, especially in some specialties like Substance Abuse because of the difference in reimbursement. For example a per diem charge for Partial Hospitalization would reimburse out of network after repricing negotiations at $1700, when an in network contract for that same insurance would pay $250 for the same code. Yes you are stuck with low reimbursements for some patients, but it evens out to a higher average than going in network.

There are advantages to going in network, but free standing facilities would need a huge bed count and keep their census always full in order to make it profitable. I am not saying this is the best or most honorable model, but its the reality of the industry.
 
Top