Wiki Out of Network Billing Strategies for Labs

[merced.lisa@gmail.com]

Does anyone have any good suggestions on out of network billing strategies to maximize provider collections either from the patient or payer?

My experience has been that since the subscriber holds the relationship with the payer, they need to call to negotiate in network repricing. If they patient is unsuccessful then the provider can do an underpayment appeal on behalf of the member with UCR rates by calculating RBVS and an average of in network rates however because the provider appeals on behalf of the patient they forfeit being able to bill the patient at that point.

Also, when it comes to balance billing there are certain states that have laws against balance billing patients even in the event the provider is out of network.

I have also working for insurance companies processing claims and we would process any lab claims as in network if the ordering provider was in network but the lab was out of network. This was with BCBS so I am not sure if any other insurance companies will process the same way. Also, if the member is PPO member with BCBS they should get in network services anywhere they go.

I need resources and suggestions on how labs can successful obtain payment when out of network. It is very hard to compete with large lab corporations but there is also a need for smaller labs that specialize in particular lab tests. Also, the patient does not have a choice in where their labs are being sent so we want to help them as well and keep a good relationship with our clients.

 

[karamac]

OON Billing Strategies

Hi Lisa,

Many of my clients (laboratories) are OON providers and they have seen an increase in denials and a decrease in reimbursement. Many payer's have increased the patient's co-sharing responsibilities for the use of an OON laboratory including a separate laboratory deductible, increased co-insurance amounts, and co-pays.

You are right that many states now have specific state laws not just for balance billing, but also now notification to the patient when an OON laboratory is used. So patient's actually do have a choice, and many are beginning to voice their choice.

In terms of strategies, the more an OON lab can communicate directly with the patient on collections of cost-sharing, and in some scenarios laboratory payments being sent directly to the patient the better.

I have not seen the negotiation strategy vs. UCR used that frequently just do to the volume of testing and then the associated claims vs. the reimbursement that is expected. In some scenarios with specialized genetic testing, or MOPATH, or PCR procedures this may work. Payers are also extending prior authorization processes across all offered benefit plans after seeing positive cost saving reductions by limiting who can actually provide the services. This is a strategy that I see more in surgical procedures etc.

It is critical for an OON laboratory to manage it's payer base. If a patient does not have OON benefits, then the OON lab is not going to get paid. So, Medicaid, Medicaid MCO's, Medicare Advantage Plans, HMO products are all red flags for an OON lab.

Hope that this helps, the prior authorization process, and how it is managed can be a key to increasing collections.

Best,

Kara