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FEATURE Protecting the Out-of-Network Option

Health plans and insurers are adopting tactics that can challenge ASCs. BY DAVID S. GREENBERG


SCs, like other health care pro- viders, face

significant chal-

lenges to remaining profitable as the industry juggles increasing la- bor costs, fierce competition and the constant threat of shrinking federal reimbursement. But one area that is causing real consternation for own- ers and operators of ASCs is the un- predictability and conflict associated with billing for and collecting pay- ment for medical services rendered out of network. For the uninitiated, medical ser- vices are considered out of network when the services are covered by the patient’s health plan, but the provid- er does not participate in the health plan’s provider network. So, while coverage of the ASC’s services ex- ists, there is no contractual relation- ship between the provider and the plan governing how much should be paid, when it should be paid and who should be paid.


Some ASCs have found that there is a significant upside to remaining out of network with many insurers, third-party administrators and health plans. Without a contract that caps payment rates for the medical services rendered, providers who are out of network are free to bill at rates that are designed to accommodate their costs and can sometimes recover more appropriate payments from plans and insurers than those typically paid to in-network/contracted providers. Operating out of network has be- come more challenging recently. Health plans and insurers have adopted in- creasingly sharp tactics to (1) reduce reimbursement paid to out-of-network providers, (2) delay payments and (3) strong-arm out-of-network


into network agreements. ASCs that operate out of network successfully un- derstand how insurers and plans apply pressure to out-of-network providers and recognize when and how to chal- lenge inappropriate conduct.


Audits Several major health insurers have been aggressively using their special inves- tigation units to institute post-payment audits targeting out-of-network provid- ers. It happens something like this: The ASC, which is out of network, renders services to a plan beneficiary and sub- mits the claim for payment. But noth- ing happens—no payment is made. The provider’s billing department follows up with the insurer to learn the reason for the delay, and when payment will occur, and learns that its claims are under au- dit by the insurer’s special investigations unit. Sometimes a reason is given for the audit, other times it is not, and frequently, the insurer will ask for additional infor- mation and documentation from the pro- vider. Meanwhile, the collection of the receivables continues to drag on. When payment is ultimately made, it may be reduced to only a small fraction of what the provider charged, with the patient left with an enormous balance due, which may never be collected.

Re-Pricers Many insurers are also hiring re-pricers, third-party companies that specialize in reducing reimbursement to ASCs and other providers, often targeting services that are rendered out of network. Some re-pricers are paid a flat amount, while others are paid on contingency, receiving a fee based on the amount of money they save the insurer or plan. Re-pricers ply their trade in a number of ways. Some- times they negotiate directly with the provider on behalf of an insurer or plan after the completion of the procedure but before payment has been made, offering to settle the outstanding claim. The offer can put the provider in a difficult posi- tion, since no payment has been made and some immediate payment may seem like a better proposition than waiting for the insurer or plan to pay the entire bill. On other occasions, the re-pricer is del- egated authority by the plan or insurer to review the provider’s claims and deny

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