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Cigna and Data iSight repricing

  1. Default Cigna and Data iSight repricing
    Medical Coding Books
    We are an out of network provider with Cigna, but yesterday I received an EOB for a claim that had been processed with a plan discount, that should not have been there. We billed $145 and the discount was $60.17 with the remaining $84.83 applied towards the patient's deductible. So I called Cigna and they stated that I have to call Data iSight (third party pricer) to have the discount removed. So I called Data iSight and they stated I have to appeal their pricing to have the disocunt removed and then I can get a corrected EOB from Cigna. How can an insurance company have these claims repriced and then send out the EOB without having the provider agree? I get requests all the time from out of network inurance companies wanting to negotiate, but they don't process the claim until they have received a yes/no from us. Has anyone else encountered this problem? How can the insurance company do this? Is this a ploy to make it difficult for an out of network provider to get paid, therefore, resulting in the provider just taking the discount or deciding to join the network?

  2. Default
    To answer your question no some insurance companies have fixed rates as to what they pay an out of network provider and they don't have to send you anything and I mean anything. We were out of net-work with ghi and they paid 47.00 on an ov for out of network and sent the 47.00 check and EOB to the PT so no if they already have these rates in place thats usually what you get your lucky they came back and paid more.
    I had a different problem with CIGNA-GREAT WEST but I thought I would vent.I am an in-network provider, and they were discounting my claims at 100% and paying nothing for all of them. It took me about 6 months to get this fixed and I still haven't seen the money yet. First they sent me to the claims dept, then prvider relations, then i had to wait for a claims specialist, then the claims specilist told me it was taken care of and it wasn't so I called CIGNA and they let them know how we weren't best freinds and despite being a provider in the real world I would not recommend Cigna to anyone I knew. They had another claims specilist call and take over but(very quickly after my comments), this was a mess and I had to keep and keep, and keep calling to make sure it was taken care of!!! What a major pain. Which reminds me it is probably time for my reminder call and see whats up I have had this problem scince FEBuary.
    Last edited by ANDREAHSANCHEZ; 10-18-2011 at 01:25 PM.

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