What makes a good Out-of-Network (OON) billing case?

June 10, 2021
by Admin

So…you’ve decided to bill out-of-network (OON) have you? Or maybe you have an ASC/OBS and you want to optimize it? Or maybe you have an amazing biller who is recommending you assess the opportunity?

Quick question: How the hell do you know which cases to take?

Short Answer: Let us know when you find one. Doesn’t exist as far as we’re concerned…or skip to the end and we have some pointers.

Long Answer: Strap up bucko…

Disclaimer: We are not insinuating in any way that you drive care based on benefits because that’s bad juju and also regulatory-wise…not kosher.

OK…with that out of the way…

This is math at its most basic.

Allowable Amount * Benefits = Potential Profit

Oh if only it were so simple. We’re going to jump from shapes to ‘rithmatic now.

Allowable = the amount you’re supposed to be paid contractually. Oh shoot that’s right…we don’t have a contract. OK so grab the nearest sharp object, imagine a dartboard on the wall and throw it. That’s what you’ll be paid. At least that’s the amount of logic we can ascertain is used by the healthcare payers lest a bit of skewing towards not paying doctors squat. Federal Law requires that you’re paid at the highest of 3 rates:

1 – Medicare (always the lowest unless you’re in Florida…which you can add to the list of reasons to leave Florida…I live here so I can say that),

2 – An agreed-upon amount AKA negotiation (we’ll touch on this later too), or

3 – Usual & Customary (U&C) – the average expected for your geographic region and procedure. So you know what to expect now right? Right…not that easy. We’ll explain later.

Benefits = patient benefits. We all know this junk. Copay/Coinsurance/Deductible. Now let’s give the concept a quick shot of HGH. So OON benefits are way trash compared to IN. Like 2-6K deductible = 10K+ deductible. Like 10-20% coinsurance = 50% coinsurance. So unless you’re planning on chasing down John and Jane Doe for all the money they have trying to survive in this country on a median “living” wage…you have to take a look at how much that insurance plan will pay. CAVEAT – we’ll cover patient hardship/financing later so don’t fret.

So…now we have:

Allowable (Agreement Factor) * Benefits (OON only) = Potential Profit.

Well done class, let’s step into geometry and rounding!

Benefits – you need to assess this BEFORE you authorize your cases. What is the point of arguing with that nurse the insurance company hired in some region of South East Asia or the Paid Pencil MD who can’t even legally render the services you’re requesting (or ever has) and is sitting behind a desk trying to tell you why you don’t know your stuff…before you even figure out if this case will pay? More and more patients have limited networks or shite benefits or NO benefits OON. Ascertain the financial upside before you waste dollars and time on getting a case approved (opportunity cost folks!).

Allowable – Note to self: THERE IS NO NATIONAL STANDARD. Yes…everyone can define U&C as whatever the hell they want to. Remember the rule of 3? Medicare < Negotiation < U&C…unless I’m a crooked corporation who pays my executives 8 figure salaries to redefine what U&C means thereby circumventing the law. Use a (formerly) well-accepted definition from a resource like FairHealth (you have to pay for it, but do it, it’s worth it). Don’t use these third-party trash systems that make their money-saving for the payers. And DEFINITELY DO NOT ACCEPT UNILATERAL BULLSHIT…like United Healthcare defining it themselves. You have no obligation to accept their self-defined rates.

Ah! Almost forgot…you know that urgent negotiation you just got that if you don’t accept right now will be half the price later and whatever other garbage they are psuedo-threatening you with? Yeah, screw them. They control nothing other than their own posturing. When you decline their BS offer it goes back to the payer and you’re no less disadvantaged than before. Those scumbags get paid for saving the insurance carriers money and there’s a special place in Dante’s 7th circle for them.

OK! Algebra time. It is all equations, right? If this, then that. Modes ponens/modes tollens and all that fun stuff. What do we mean?

All the shit you deal with for IN billing. Expect 10x the headache. Your paperwork will get lost (* cough * shredded * cough*). Your operative report will get “mismatched” with your claim. You’ll violate that timely filing constraint you never agreed to. You’ll get hung up on. You’ll sit on hold for hours. You’ll lose years of your life from the stress of dealing with this BS. Or you’ll hire an expert as your sacrificial lamb. Basically what we’re saying is billing is so annoying we will die for you one minute at a time listening to the Yanni-inspired hold music from the insurance companies while we fight to get you paid. We’re basically heroes without capes. This is a game of block and tackle. We’re the Waterboy meets Tyson (pre-Hollifield ear bite unless you hang up on us), meets Perez Hilton (cuz we talk trash when we need to sweetie) 😉


OK Calculus and then we’re done…

Keep your financial processes in order. That means you have a financial process. Yes, you. You have financial processes.

1) You collect up front to protect your bottom line. Depending on where you’re at in your career or in the nation geographically you may or may not be able to command your full cosmetic self-pay (discounted) price as a deposit. REMEMBER: your cosmetic pricing is a self-pay discount from your standard insurance fee schedule which you give your patients for paying in cash upfront and avoiding the administrative burden of standard insurance filings. If you cannot collect this full amount, you may have a standard price that is a bit lower and near your preference card cost (Cost of Services – don’t know what that is…you need a good bookkeeper don’t you?). We don’t advise it, but we’ve seen some folks risk it and collect nothing upfront as well. You gotta make the sale…but at what cost is up to you.

2) You do not and will not write off ad hoc and/or subjectively. You have a defined process your patients have agreed to in writing that allows you to adjust balances after insurance processing in line with said agreement. We all understand that if we do in fact write off, it can be misconstrued by the baddies as “fraud” if we arbitrarily adjust on a routine basis. Need forms? If only you had a good resource…

3) You are not going to open the mail every day waiting for that check and expecting a 20 day DRO (Day Rev Outstanding = standard billing KPI = how long until you get paid). OON takes time. Expect it to. If you can’t handle being patient from a personality type standpoint or from a cashflow standpoint…this model ain’t for you

OK! You passed. Now don’t do any math because it sounds like a nightmare right? Just hire Auctus and we’ll do all of it for you!

Hot Tips (for the cheaters that didn’t read):

1) 10K U&C Case size is your minimum. If you’re not at 10K don’t bother.

2) Don’t take patients who expect their money back at the end. This is not a rainbow process. You are not a leprechaun. They will bother you until you pay them to go away or they’ll leave a shite review and cost you even more on reputation management.

3) PLASTIC SURGEONS: This means you love these cases – breast recon, breast reduction, panniculectomies w/ myo flaps and hip lipectomy, myo/fascio flaps, aug revision w/ Bakers 3+ and/or rupture, NSR cases w/ spreader grafting/turbinate work, gender-affirming surgeries etc. You do not love any other cases such as, but not limited to: lumps/bumps, Mohs recon, blephs, lipo, septos, scar revisions, office procedures in general, consults, office visits, laser stuffs, etc.

Capisce? Don’t force it. It will not work. Your biller is great at working the system if they’re great. They are terrible at changing it even if they are great.

4) DERMATOLOGISTS: Run far, far away. This is not for you. Period.

5) Geozip matters. It doesn’t make sense but que sera, sera, folks. Chicago pays 50% less than Kenosha because you cross the magic border into cheese land (I’m from MN so I can say that, and also the Packers suck). New Jersey is a unicorn. Florida is trash. You’ve got everything in between. Check FairHealth to see where you land or just call us already.

6) IF you have an ASC & you can bill for it in your state (yes it matters)…you should care approximately 10% about your professional services bill(s) and focus on your facility. That is your Golden Goose. You need accreditation and maybe a CON. You also need a consultant to navigate…boy where could you find such a consultant?

7) IF you have an anesthesia service…it is your lame duck. It will do nothing but eat up your patients’ OON deductible. Hire an outsourced firm. Let them deal with the headache.

That’s all folks. Give us a ring for questions/concerns/more hot tips.

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