“Let’s Make A Deal”

“Let’s Make A Deal”

If you’re billing insurance out of network, you will eventually receive faxes or emails like this: 

                                                                                                                                                      

Who are these people, and why are they contacting me? 

There’s a whole industry of third-party re-pricers and “passive PPO’s.” Multiplan is just one of many out there.  

A what? 

A “re-pricer” is just what it sounds like: an entity that looks at a claim and decides what is the “allowable” amount. 

Sometimes, it’s not who you think it is who decides how much you’ll be paid….. 

A “passive PPO” is an alternative provider network that serves as a backup to the original payer’s panel, another method to force a discount on out of network claims.  

Here’s the shell game: You are out of network but submit a claim to an insurance payer so that the patient can get out of network reimbursement.  (It doesn’t matter whether you’ve accepted assignment or not). The payer looks at the claim, your NPI/tax ID and sees that you are out of network. 

If the payer, let’s say it’s Cigna, has an arrangement with a third-party party re-pricer such as MultiPlan, then the claim is sent to MultiPlan by Cigna before any action is taken.  

MultiPlan’s job is to contact the doctor (YOU) and offer a discount. Keep in mind that they don’t work for free, either.  

Where is their payment going to come from? Your reimbursement, of course! 

The fax makes it sound as if you won’t get paid promptly unless you agree to the discount.  

“Your acceptance may expedite payment…” 

They mislead a lot of people into giving discounts with that language. Don’t be fooled. All states have “prompt payment” laws that specify how long an insurer has to adjudicate a “clean” claim. If the claim was sent to Multiplan, then by definition, it was accepted for adjudication and is “clean.” If the insurer doesn’t respond within the time frame, they must pay you interest. 

By telling you acceptance of these terms means you will decrease your patient’s cost share, this is true…but not the whole picture. Acceptance does reduce the amount the patient has to pay, but it does NOT put you into the network or shift the benefit level back to “in-network.” The patient will still only receive the out of network benefit level.  

If your reason for being out of network is to reject low insurance rates, signing this fax relinquishes this advantage. 

When you receive one of these offers: 

It is ok to ignore it and within a couple of days the passive PPO is required to return the claim back to the payer, who will process it as they originally would have done without the re-pricer’s involvement. 

If I have time, I enjoy calling them and (politely) telling them to get lost. I also ask them to remove the provider’s TIN / NPI from this member’s claims. Otherwise, they will continue to send offers for each date of service. 

If the patient paid in full at the time of service and you are filing for them to be reimbursed (or if the re-pricer is responding to a superbill submitted by the patient), do not negotiate; you will be cheating your patient unintentionally. 

If your patient is having financial difficulties affording out-of-network treatment, this is a legal way to offer a discount on the full billed charge after the claim is submitted.  

You *will* receive these offers even if the patient’s deductible has not been met. If you have agreed to the discount, you cannot charge the patient what you originally billed; you must charge them only what you agreed to. 

If it’s a situation where you thought you were in network for a particular patient, and then you turned out not to be, accepting a discount might smooth over difficulties from a clinical perspective. 

Be careful not to mark the box that says, “I accept a global fee agreement to eliminate the need for case by case faxes.” This puts you in network with the passive PPO…and forces discounts with any payer who chooses to hire them. You will be giving discounts where you don’t intend to – but the patients won’t get better benefits unless the passive PPO is their primary network (it can happen, with smaller payers). 

You will not receive these offers if the patient has no out of network benefits.  

Whatever your reasons for considering a deal, you can certainly attempt to get a better rate than what they first offer. I’ve found reps willing to go as high as 50% of the amount they are trying to write off.  

Re-pricers only have the power to adjust the final allowed amount; they do not get to determine what/how much is covered, paid, denied, or applied to the deductible. Nor can they quote benefits. For any of that, you must continue to work with the payer.  

Still need help? Contact Your Billing Buddy!

We won a great victory – Does anyone know about it?!?

We won a great victory – Does anyone know about it?!?

Transaction #: 123456789

Card Value: $1,500.00

Date: April 1, 2021

When I see this…

  • Why should the clinician have to pay to be paid?
  • Why do doctors have to spend time manually entering all these – there’s not even a QR code or a way to swipe them! Time is money too!
  • How much do you want to bet that the insurance company and Mastercard/Visa are splitting that merchant fee as a “kickback?”
  • They are making me log onto 10,000 different websites to get my remittance information for posting, rather than sending it to me in the mail or via my clearinghouse/software! That is SUCH a waste of my time.
  • They’re saving themselves time and money, at the doctor’s expense!
  • Payers know the doctors don’t have time to figure out these complex enrollments, so they count on people giving up and charging the virtual cards – and they are right.

NO … I’m not opinionated or anything…

Since 2014 when I received the first “Virtual Credit Card” (yes….it really WAS that long ago), the number of payments received in this format has proliferated like, well …..Tribbles.

It used to just be an annoyance, but all you had to do was call and they’d (grudgingly) send you a check.

Now, here’s what happens:

  • Plans will refuse to allow enrollment in automated remits (ERA) unless the provider agrees to accept VCC or direct deposit, often from third-party intermediaries.
  • Often the direct deposit option requires a fee also, which currently can be as high as 2.5%.
  • Some plans refuse to pay by check at all. It’s either direct deposit or virtual card. Even if you’re out of network, out of area, or you only do business with them once every 5 years. Doesn’t matter.
  • If they do agree to pay by check…it can take the check months to arrive, after several phone calls to follow up.
  • The direct deposit registration process is often handled by third-party intermediaries and is incredibly complex and takes months. Which, frankly, I don’t understand. I go to my power company’s website and pay my bill in under 5 minutes simply by entering my routing & account #’s. So why does direct deposit registration with payers take months?

Now that I’ve raised your blood pressure to stroke levels….I have amazing news! We have won a victory over this abuse.

No way, really????

I know, right? Here’s how we fight these virtual cards and unreasonable-fee intermediaries:

On March 22, 2022, CMS quietly issued the following two guidance letters. In dry HIPAA-ese, they upheld providers’ rights.

For Health Plans: https://www.cms.gov/files/document/guidance-letter-vcc-eft-era.pdf

For Health plan vendors/business associates: https://www.cms.gov/files/document/guidance-letter-business-associate.pdf

Help! Is there an English version? I clicked the links, but what does all this gobbledygook mean? What do I need to do?

(Click here for the explanation and permanent solution to this pernicious skimming away of your hard-earned reimbursements.)

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