The complex out-of-network reimbursement landscape contains vast opportunities for ASCs looking to improve their profit margins. However, there are many considerations ASCs should keep in mind to successfully pursue an out-of-network model.
Here are five key thoughts Richa Singh, executive vice president of Collect Rx, shared during a presentation on increasing profits through out-of-network reimbursement at the Becker's ASC 24th Annual Meeting: The Business and Operations of ASCs in Chicago Oct. 26.
Why ASCs should pursue out-of-network reimbursements
"There aren't really many ways to increase reimbursements," Ms. Singh said. "Your contracted rates are hard to change … Medicare and Medicaid reimbursements … are what they are, you can't do anything about that. Out-of-network really represents [a] great opportunity. … Out-of-network reimbursements are higher, sometimes significantly higher, than in-network reimbursements."
Don't underestimate the appeal process
"There is an appeal process that needs to be incredibly rigorous," she said. "The insurance company is underpaying you. They're banking on [the fact] you've got so many other things going on, that … they pay you 20 percent of your billed charges and it's done … Your job is to go back and get them to increase those [out-of-network] reimbursements, and you have to go [forward] with this appeal process."
Pick up the phone and get the payer talking
"You want [the insurance companies] to talk. You want them to explain to you, verbally, why they reduced the charges," Ms. Singh said, noting the importance of avoiding online portals. "The only two things for most of these portals is that you … accept or decline. You can't counter-offer on them. Make sure on those portals that you're able to at least counter-offer, otherwise deal with the paperwork and get rid of it."
Understand your out-of-network insurer's 'explanation of benefits' inside and out
"Make sure that you read your EOBs," she said. "These insurance companies are making it hard to decipher what's happening on these EOBs. They make it incredibly difficult to understand why they underpaid you. … Check those EOBs, because if you don't, you're definitely losing money. They're using all different ways to try to reduce [your reimbursement]."
Don't go 100 percent out-of-network — Try a hybrid approach
"We suggest that you do a hybrid approach, meaning you're in-network with some, and out-of-network with others. We've found that is the best approach for ambulatory surgery centers [to increase revenues]," she said. "We suggest that you dip your toe in the waters and you take one contract at a time, go ahead and cancel it. … While you are out-of-network with that one contract, really take the time to hone your out-of-network process. Do so over a four- to six-month period and then evaluate your reimbursements to see if it is plausible to cancel the next contract."