Create an Out-of-Network Work Flow to Maximize Reimbursements

Product Id : HE156
Instructor : Thomas Force
Jul 25, 2019 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 60 Minutes

Many physicians and other healthcare practitioners ("practices") need to go "in-network" with managed care organizations because these network agreements drive patients into their office. These practitioners typically enter into managed care participation provider agreements with the health insurers for the privilege of becoming an "in-network" provider.

Out-of-network providers receive payment for services directly from the patients—and patients receive out-of-network payments from their insurance company if certain conditions are met. Though going OON can bring higher reimbursements, it may also lead to increased claim scrutiny and higher patient cost sharing. However, currently OON reimbursement is on the decline since many health plans have changed their reimbursement rates from a usual and customary formula to a percentage of Medicare.

In this 60-minute session, Thomas will discuss the challenges providers face while obtaining adequate reimbursement when out of network. He will shed light on ERISA and how this act obligates insurers, plan administrators, benefit providers and patients with certain rights. Find out ways to avoid raising a red flag; policies to implement; and forms to use. Learn about appeals process—time frames, applicable bases for no benefit and low benefit determinations; disclosures and how to stay out of trouble; balance billing, recoupments, and more!

Session Highlights:

  • Effective techniques for Balance Billing.
  • Federal Prompt Payment requirements and Take backs and recoupment defenses.
  • Best practices to reduce the risk of fraud allegations.
  • Different strategies for In-Network v. Out-of-Network claims.

Who Will Benfit:

  • In-Network and Out-of-Network Practitioners and Facilities
  • Office staff and Billing Managers
  • Healthcare attorneys
  • Healthcare billing companies
Speaker Profile:

As a state and federally licensed attorney in both New Jersey and New York, Mr. Force has over 30 years of experience in the healthcare and insurance industries. His success as a Wall Street insurance litigator and his tenure as General Counsel for a New York-based Accident and Health Insurance Company where he served as Chief Compliance Officer propelled the founding of The Patriot Group.

The Patriot Group is a full service revenue recovery company that provides billing, collections, and follow-up services as well as assistance with managed care appeals, managed care contracting, credentialing and compliance.

Mr. Force is nationally recognized as an expert in revenue collection techniques, managed care contracting and appeal strategies.  Mr. Force remains an active member and frequent speaker on managed care and collection techniques for the Health Finance Management Association, the Suffolk County Bar Association, and other organizations.

Mr. Force is nationally recognized as an expert in revenue collection techniques, managed care contracting and appeal strategies.  Mr. Force remains an active member and frequent speaker on managed care and collection A United States Marine, Mr. Force received the prestigious Meritorious Mast Award for Leadership in 1987. Mr. Force is also co-Chairman of the Health and Hospital Committee of the Suffolk County Bar Association. He is co-founder of the Healthcare Reimbursement Attorneys Network, a national association of attorneys that represent physicians and hospital clients. Mr. Force also works closely with the American Medical Association and various state Medical Associations.echniques for the Health Finance Management Association, the Suffolk County Bar Association, and other organizations


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