Wiki Facility ASC REIMBURSEMENT

[ShauntaEskridge]

Hello all, your input and advice is very much appreciated. I currently work in an ASC and our reimbursement rate has drastically went down with most payers. We are OON and we take all insurances but the payments lately have been 1K/2k range and negotiations with the insurance and all appeals have result in no additional pay. Please all comments are welcome

 

[thomas7331]

As an out of network provider, you have very little leverage with insurance companies to negotiate rates. But if you are out of network, then the balances should be paid by the patients, so it shouldn't affect your total reimbursement. Are you not making payment arrangements with the patients or collecting up front to ensure that they will cover any balances that aren't paid by their insurance if they choose to use an out of network provider?

 

[ShauntaEskridge]

This practice only collects deductibles, and waives the coinsurance. But feels like the insurance should be paying more. I’ve tried to explain why we should and could gain more revenue by collecting both deductible and coinsurance but they insisted the this is balance billing and I know it is not

As an out of network provider, you have very little leverage with insurance companies to negotiate rates. But if you are out of network, then the balances should be paid by the patients, so it shouldn't affect your total reimbursement. Are you not making payment arrangements with the patients or collecting up front to ensure that they will cover any balances that aren't paid by their insurance if they choose to use an out of network provider?

 

[thomas7331]

This practice only collects deductibles, and waives the coinsurance. But feels like the insurance should be paying more. I’ve tried to explain why we should and could gain more revenue by collecting both deductible and coinsurance but they insisted the this is balance billing and I know it is not

Every provider I've ever met in my career 'feels like the insurance should be paying more.'

Wanting it won't make it happen though - you've got to have some kind of leverage. If you're out of network, then you don't have the leverage of being able to say that you'll leave the network or stop seeing their patients if they don't pay what they agreed to pay in the contract. Without that, the only way to successfully appeal is to be able to have some kind of basis for showing that the insurance paid incorrectly, for example a state or federal law or regulation, a patient's plan document, a payer policy, etc. that says that it should have been paid a particular way but which the insurance neglected to follow.

Incidentally, your practice could be out of compliance with false claims laws by waiving coinsurance, not to mention that it sounds like you may unfortunately just be dealing with poor business/financial management there.