Leaders in Maximizing Out-of-Network Reimbursements
Cohen Howard is a recognized leader in the health insurance industry as a single-source solutions provider of services to maximize reimbursements for out-of-network providers, including analyzing, interpreting, advising, and taking action on legislation that impacts reimbursements.
For example, the No Surprises Act (NSA), which goes into effect, in part, for plan and contract years commencing on or after January 1, 2022, prohibits providers from billing patients for amounts that exceed the in-network cost-sharing obligations due under a patient’s health insurance plan for certain types of services.
Generally, services for emergency care, post-stabilization care and out-of-network services provided at an in-network facility are governed by the No Surprises Act, unless with respect to certain services the patient has been provided notice and consented to the out-of-network services. The statute applies to all group and individual plans, including ERISA, Non-ERISA, fully insured and self-insured health plans.
For claims that fall under the NSA, the out-of-network fee schedule in a patient’s health plan will not apply in calculating the amount of reimbursement paid to the provider.
How “No Surprises Bills” Will Impact Reimbursements for Providers
Out-of-network providers with underpaid or denied claims that are subject to the NSA can challenge the reimbursement amount following receipt of an initial payment or denial notice for services rendered from the payor. The bill provides a framework for handling disputed claims through a binding Independent Dispute Resolution (IDR) process.
The time frames for providers to comply with the requirements of the NSA are very narrow from receipt of the initial EOB, and providers need to begin implementing processes now to be ready for the changes coming in 2022.
How Do You Maximize Payor Collections?
Employing an effective strategy to increase claims reimbursement from payors is mandatory for out-of-network providers. With ongoing changes in healthcare legislation and regulations such as the Federal No Surprises Act and other State-specific laws expected to continue, together with the delay, deny, and deflect tactics used by payors, the process of getting fairly paid for services rendered is becoming more complex and increasingly difficult.
At Cohen Howard, our practice is focused solely on increasing revenues for OON providers nationwide. We are a single-source solution with a collaborative team, led by attorneys and comprising professionals with expertise in commercial insurance, medical billing and coding, ERISA, and other Federal and State-specific healthcare laws that impact payor reimbursements.
Our team is highly skilled at increasing providers’ revenue recovery through pre-service authorizations, negotiations, administrative appeals, pre-litigation, and litigation, and we have recovered more than $100 million in payments for our clients.
Our Process for Seeking Revenue Recovery for OON Providers
We’ll start by conducting a comprehensive assessment of your claim to determine the most prudent course of action. Depending on the facts of your case, we’ll pursue one or more of the following steps:
- Preservice Authorizations: Obtaining In-Network GAP exceptions or single case agreements can be challenging. Our team works to secure these agreements and follows through to ensure proper payment is made once services have been rendered.
- Appeals: Using substantive medical and legal arguments, we are able to effectively challenge underpaid or denied surgical and facility claims. For those claims not resolved during the appeals process, we ensure that the administrative record is properly established to preserve providers’ rights to take action if settlement is not achieved through the negotiations, appeals, or pre-litigation demands.
- Negotiations: For claims that fall under the NSA or certain State surprise bills, we have dedicated resources to help providers respond to negotiations received from payors, prior to, after, or as a result of State surprise bill laws. Often, these negotiations require timely responses, and our established processes and in-depth knowledge of payments made by payors for similar claims help to maximize reimbursements through negotiations. With implementation of the NSA, the level of negotiation activity is expected to increase significantly.
- Independent Dispute Resolution: Many State surprise billing laws have specific dispute resolution processes that involve different forms of arbitration. For NSA claims, the payor and provider are granted a 30-day period for open negotiations. Should the parties be unable to reach a payment agreement at the end of 30 days, either party, within four days, may initiate “baseball-style” Independent Dispute Resolution (IDR). Beginning in 2022, understanding how to determine whether a payment dispute is subject to this process and whether the claim would be appealed through the plan or pursued through a specific State surprise billing law or under the NSA will require a comprehensive understanding of Federal and State laws and a patient’s plan documents.
- Pre-litigation Demands: As a law firm, Cohen Howard is able to continue past the administrative process to pursue additional payment for under-reimbursed or denied claims through pre-litigation efforts. Our firm engages in ongoing efforts to seek further reimbursement by working with plan administrators, regulators, and payors.
- Litigation: We will evaluate the viability of filing suit for claims for which a settlement has not been achieved through other actions to maximize reimbursements. Our team, together with outside litigation firms, provides aggressive, effective representation to seek favorable outcomes.
Contact Us to Explore Your Claims Reimbursement Options Today
Discover how the experienced team at Cohen Howard can help you maximize OON claims reimbursements and remove the barriers and burden of collecting payments from payors. Contact us online to learn more about our services. To schedule a free consultation with one of our attorneys, call us at 732-747-5202 today.