Wiki Cigna and Data iSight repricing

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kinger70

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We are an out of network provider with Cigna, but yesterday I received an EOB for a claim that had been processed with a plan discount, that should not have been there. We billed $145 and the discount was $60.17 with the remaining $84.83 applied towards the patient's deductible. So I called Cigna and they stated that I have to call Data iSight (third party pricer) to have the discount removed. So I called Data iSight and they stated I have to appeal their pricing to have the disocunt removed and then I can get a corrected EOB from Cigna. How can an insurance company have these claims repriced and then send out the EOB without having the provider agree? I get requests all the time from out of network inurance companies wanting to negotiate, but they don't process the claim until they have received a yes/no from us. Has anyone else encountered this problem? How can the insurance company do this? Is this a ploy to make it difficult for an out of network provider to get paid, therefore, resulting in the provider just taking the discount or deciding to join the network?
 
To answer your question no some insurance companies have fixed rates as to what they pay an out of network provider and they don't have to send you anything and I mean anything. We were out of net-work with ghi and they paid 47.00 on an ov for out of network and sent the 47.00 check and EOB to the PT so no if they already have these rates in place thats usually what you get your lucky they came back and paid more.
I had a different problem with CIGNA-GREAT WEST but I thought I would vent.I am an in-network provider, and they were discounting my claims at 100% and paying nothing for all of them. It took me about 6 months to get this fixed and I still haven't seen the money yet. First they sent me to the claims dept, then prvider relations, then i had to wait for a claims specialist, then the claims specilist told me it was taken care of and it wasn't so I called CIGNA and they let them know how we weren't best freinds and despite being a provider in the real world I would not recommend Cigna to anyone I knew. They had another claims specilist call and take over but(very quickly after my comments), this was a mess and I had to keep and keep, and keep calling to make sure it was taken care of!!! What a major pain. Which reminds me it is probably time for my reminder call and see whats up I have had this problem scince FEBuary.
 
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UHC and Data iSight

We had a similar situation with United Healthcare and Data iSight. We are also an out of network provider but were granted an in-network benefit exception since we are the sole provider of our durable medical equipment. Due to our out of network status, our claim was sent to Data iSight for repricing. For a $13,800.00 claim for customized DME, Data iSight repriced our claim to allow $398.31, .02% of billed charges. United Healthcare then paid the claim at the customer's in-network benefit level due to the benefit exception. Data iSight's motto is "transparency for all", however they were unwilling to explain how they calculated such a low payment. When we tried to appeal this low payment with UHC with previous payment history at 90% of billed charges for in-network exceptions, our appeals were denied stating we must contact Data iSight. Three of our other claims that were sent to Data iSight were allowed at 75 - 80% of billed charges, however we were told that they had more flexibility to negotiate on those claims based on the customers plan. It doesn't appear that they have any standard methodology for pricing out of network claims. This process leaves out of network providers in a position to either accept a drastically reduced payment for not provide medical care. It seems criminal to me! When verifying benefits prior to services being rendered, the customer service department does not know if out of network claims will be sent for repricing and the claims department will not disclose any information unless there is a claim on file. There must be a way to stop this practice or at least require insurance carriers to disclose up front that our out of network claims will be sent to a third party vendor for pricing. Needless to say, we filed a complaint with the better business bureau and are waiting for a response.
 
You do have some recourse. UHC and Cigna both use Data iSight for self funded plans. Self funded plans are governed by Federal ERISA law. If you have high dollar claims, I would retain an ERISA attorney to do the appeals and recovery. We used ERISA Revenue Solutions to recover underpaid spine surgery and orthopedic surgery claims.

Another option is to bill the patient and encourage the patient to call and demand correct payment according to their OON benefits.
 
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