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