Out of Network: 6 Frequently Asked Questions

By Richa Singh  bio

As labs face an increasingly challenging reimbursement environment, more providers are doubling down on out-of-network strategies to maximize on collections opportunities.

Negotiating higher reimbursements on out-of-network bills can significantly improve a provider’s bottom line. At Collect Rx, we’ve helped providers negotiate higher reimbursements on out-of-network bills since 2006. The organization has grown to serve 800 customers across the nation, and its experts process more than $1 billion in out-of-network claims annually.

6 Frequently Asked Questions

Here are some frequently asked questions that we get from providers on out-of-network issues, payment processing, insurance policies, negotiating settlement offers, appealing underpayments, and third-party rental network agreements.

1. Why would I want to be out of network?

Compared to in-network reimbursements, which leave no room for negotiating rate increases, out-of-network reimbursements are often much higher.

Leveraging out-of-network represents the last great opportunity for many providers to bring more dollars in the door to improve their bottom line.

2. Is it worth the trouble negotiating if we don’t see a lot of out-of-network bills?

Out-of-network bills should always be negotiated. They present ample opportunity to increase reimbursement, as insurers usually only pay a small fraction of the bill charges.

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Even labs with low volumes that have a strong negotiation process, they’re able to generate significant additional revenue that would be enough to cover the cost of one or two full-time employees.

3. How can two patients with the same test completed and the same insurance company have two different reimbursements?

Ultimately, it’s not the insurance company that defines the reimbursement levels. Rather, that decision is controlled at the employer-group level.

4. Given there is no contract, what is the incentive for labs to agree to a settlement offer when they are out of network with the payer?

There is greater opportunity to maximize reimbursements because the majority of the time if you do not negotiate, the bill may be repriced at a much lower amount, typically close to Medicare rates. There’s also a higher possibility of favorable negotiations up front as opposed to appealing on the back end. In addition, labs can receive payment much faster when they agree to settlement offers.

5. Can out-of-network labs appeal low reimbursements for claims?

Yes. Every lab should put together a comprehensive appeal process to combat payers when they have been severely underpaid.

6. What is the No. 1 key to successful out-of-network negotiations?

Persistence is the most important part of successful out-of-network billing.

It’s what we like to call the persistence game. Who is going to win the battle of the wills? To succeed, you must have the persistence required to keep fighting for reimbursements.