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Best Practices for Handling Out-of-Network Claims in Revenue Cycle Management (RCM)

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Handling out-of-network (OON) claims can be one of the trickiest aspects of Revenue Cycle Management (RCM) for healthcare providers. These claims typically present unique challenges, including lower reimbursement rates, more complex billing procedures, and increased chances of claim denials. However, with the right strategies in place, you can effectively manage out-of-network claims and ensure that your practice receives the reimbursement it deserves.

In this article, we’ll cover the best practices for handling out-of-network claims, from verification and preauthorization to billing and follow-up, helping you navigate these challenges with confidence. Plus, we’ll explain how outsourcing services like Staffingly, Inc. can help streamline these processes, saving you time and improving your revenue cycle performance.

Key Takeaways

  1. Know your payer contracts and out-of-network policies.
  2. Verify patient eligibility early in the process to avoid surprises.
  3. Request preauthorization when necessary to secure payment.
  4. Submit accurate and detailed claims to minimize denials.
  5. Communicate clearly with patients about out-of-network costs and responsibilities.
  6. Outsource complex tasks like coding and billing to reduce errors and improve efficiency.

What Are Out-of-Network Claims?

Out-of-network (OON) claims occur when a patient receives services from a healthcare provider who does not participate in their insurance plan’s network. As a result, insurers typically pay a lower percentage of the costs, and patients may be responsible for a larger share of the expenses. Handling OON claims involves several additional steps compared to in-network claims, and failing to follow proper procedures can lead to denials, delays, and patient dissatisfaction.


Best Practices for Handling Out-of-Network Claims

1. Understand Your Payer Contracts and Out-of-Network Policies

Before you begin processing OON claims, it’s crucial to understand how each payer handles out-of-network services. Some insurance companies may offer partial reimbursement even for out-of-network providers, while others may only cover emergency situations or urgent care. Knowing these policies upfront will help you set accurate expectations for both patients and your internal teams.

  • Review payer contracts: Ensure you understand reimbursement rates, coverage limits, and other important details.
  • Clarify emergency services: Many insurers are required to cover emergency services, even if the provider is out-of-network.
  • Familiarize yourself with reimbursement rates: Some insurers may offer a higher reimbursement percentage for OON claims than others.

2. Verify Patient Eligibility Early

Verifying insurance coverage is crucial, particularly when dealing with out-of-network claims. Early verification helps to avoid surprises when submitting claims and ensures that you have all the necessary information to move forward. Many OON claims are denied simply because the insurance company has not been properly informed about the provider’s network status.

  • Verify patient insurance details: Confirm whether the patient’s insurance covers OON care and, if so, what portion will be reimbursed.
  • Ask for details: Request clarification on co-pays, deductibles, and out-of-pocket maximums that may apply to OON services.

3. Request Preauthorization When Necessary

Some insurance plans require preauthorization for out-of-network services. Failure to obtain preauthorization may result in claim denial or reduced reimbursement. Even if preauthorization is not required, it can be a helpful step in ensuring that the insurer will cover some of the costs.

  • Request preauthorization: If required by the payer, ensure that you obtain preauthorization before delivering services.
  • Document all communications: Keep records of any correspondence with the insurer regarding preauthorization for future reference in case of denials.

4. Accurate and Detailed Claims Submission

Submitting claims for out-of-network services requires extra attention to detail. Incorrect coding, missing information, or improper documentation can result in claim rejections or delays, forcing you to go through the resubmission process. Accuracy is key to ensuring timely payments.

  • Use correct medical codes: Ensure that all medical services are properly coded using the latest ICD-10, CPT, and HCPCS codes. Mistakes in coding are a common reason for claim denials.
  • Document services thoroughly: Provide detailed documentation of all services rendered, especially when treating out-of-network patients. This can help ensure that the insurer understands the scope of care.
  • Submit the appropriate forms: Some payers may require different forms or additional documentation for out-of-network claims, so ensure you know which forms are needed.

5. Communicate Clearly with Patients

Clear communication with patients is essential when handling out-of-network claims. Patients need to understand their financial responsibilities and what to expect regarding coverage and payment. Proper communication upfront can prevent misunderstandings and improve the patient experience.

  • Inform patients about out-of-network status: Let patients know if your services are out-of-network, and explain the potential impact on their out-of-pocket costs.
  • Provide cost estimates: Whenever possible, provide patients with an estimate of what they will owe for OON services, so they are not caught off guard by large bills later.
  • Offer payment plans: Consider offering payment plans or financial counseling to patients who may struggle with the increased costs associated with out-of-network care.

6. Outsource to Experts for Efficiency and Accuracy

Handling out-of-network claims can be a complex and time-consuming process. Outsourcing certain tasks can help ensure that claims are processed accurately and efficiently, reducing the likelihood of errors and rework.

For example, Staffingly, Inc. provides outsourced medical billing and coding services. By leveraging their expertise, you can ensure that out-of-network claims are accurately processed and submitted with all the necessary information. This reduces the administrative burden on your internal staff and helps accelerate reimbursement.

  • Outsource medical coding: Medical coders with expertise in out-of-network billing can ensure that claims are correctly submitted and compliant with payer requirements.
  • Leverage insurance verification services: Outsourcing insurance verification can help confirm coverage details before services are rendered, preventing unnecessary denials.

What Did We Learn?

Handling out-of-network claims requires a structured and thorough approach to ensure that your practice receives fair reimbursement while minimizing delays and denials. By verifying insurance details, requesting preauthorization when necessary, submitting accurate claims, and communicating clearly with patients, healthcare providers can streamline the process. Outsourcing key tasks like insurance verification, coding, and billing to trusted partners like Staffingly, Inc. can further improve accuracy and reduce administrative overhead.

By implementing these best practices, you can effectively manage out-of-network claims and ensure that your practice is financially protected, even when treating patients outside your network.


FAQ

Q: Why are out-of-network claims more complicated than in-network claims?
A: Out-of-network claims are more complicated because insurance companies often pay less for these services, and they may have specific documentation and preauthorization requirements. Additionally, the patient may have higher out-of-pocket costs, which can complicate billing.

Q: What should I do if my out-of-network claim is denied?
A: Review the denial reason carefully, correct any errors, and resubmit the claim with the necessary documentation. If the issue is unclear, contact the payer for clarification.

Q: Can outsourcing help with out-of-network claims?
A: Yes, outsourcing to experts who specialize in out-of-network billing and coding can ensure that claims are processed accurately, reducing the chance of errors and denials.

Disclaimer

The information in our posts is meant to inform and educate both healthcare providers and readers seeking a better understanding of the prior authorization process. However, it is not a substitute for professional advice. Insurance requirements, policies, and approval processes can vary widely and change over time. For accurate guidance, healthcare providers should consult directly with insurers or use professional resources, while patients should reach out to their insurance providers or healthcare professionals for advice specific to their situation.

This content does not establish any patient-caregiver or client-service relationship. Staffingly, Inc. assumes no liability for actions taken based on information provided in these posts.

For tailored support and professional services,

please contact Staffingly, Inc. at (800) 489-5877

Email : support@staffingly.com

 

About the Author: Noah Thomas is a revenue cycle management expert, specializing in optimizing financial processes, billing, coding, and reimbursement systems to improve healthcare organizations’ efficiency and revenue.

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