Wiki Per Claim Negotiations When Out Of Network

[martinni1974]

Here is a little tip for those of you who entertain reimbursement negotiations when you are out of network.

Before signing those agreements make sure you ask the payer or "negotiator" the following questions:

Is reimbursement based on the billed charges or does it apply after the claim is edited.

What guidelines will be used if the claim is prospectively audited.

ASCs: many payers utilize OPSI/OPPS guidelines for implants/supplies. Make sure the agreement states you will be exempt from those industry standards or you will not be reimbursed for anything that is OPSI packaged.

After asking these questions make sure the agreement contains this specific language prior to signing any fee negotiation agreements.

 

[CLCameron]

Those are great points to hit when considering a negotiation

I would add that if your office does not want that negotiated percentage to become a binding contract for all future claims from your office, that you review the agreement completely to make sure that there is no clause in there that indicates this (I have run across this tactic many times).

I would also have them include the actual amount they will be reimbursing versus what they will make the patient responsible for. Negotiating a $10,000.00 settlement on a larger claim is great, but may not necessarily be what your office is going for when they come back with a $2,000.00 check and $8,000.00 patient responsibility.