I work 100% out of network.
On the verification side, you should ask if OON pricing is done based off the Usual and Customary Rate (UCR), an Out of Network Allowed, or a % of the CMS rate. For BCBS plans, ask if the pricing is done by the home plan or local. If it is priced by the local, then you are stuck with whatever pricing method they use.
If the pricing is based on an allowed, or a % of the CMS rate, you are pretty much stuck with that reimbursement. You can try an appeal, but they will have pretty consistent price table to work off of.
If the pricing is based off the UCR, then a few things can happen.
1. The claim will be repriced by a 3rd party company such as Multiplan or HRGI. There might be restrictions like MNRP for UHC, or MRC1 and MRC2 for Cigna. Sometimes you can negotiate for a % of the billed amount. You can even create global agreements for a fixed amount, or create a network contract with Multiplan that will keep you out of network with the insurance, but keep pricing consistent.
2. The claim will go through a different 3rd party company that will go through a regional price table. Viant and Data I-sight are such companies. You are usually stuck with these repricings.
3. If the claim is Aetna, it may be repriced through their in house company (Global Claims Service) When they are priced by Global, this is the only method I know that allows the facilities advocate for the patient. Not all claims are repriced by Global. There should be a 1-800 number on the EOB to contact them and they will send you a pre-made spreadsheet to send back the claims.
If you are going to send a pricing appeal, You would only be able to do that if the pricing is based off the UCR. I would try to fight for some sort of aggregate amount and not try to gouge. (I wouldn't ask for $1200 for a procedure in which the CMS rate is $40)
Also note that if it is a Union Based plan, they are exempt from most regulations created by the ACA that other self funded plans would be bound to. There is very little chance that you would get anywhere with those type of policies.
I hope this helps