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For many of us, we have watched presentations, read articles, engaged consultants, or even had internal discussions focusing on appeals management and aging account receivables. Over the years, we have all heard about the high percentage of appeals that are avoidable. We have heard about ways to combat denials. But are they effective? Are they covering everything we need to cover.
After a year since the passage of the federal No Surprises Act went into effect, we are still learning about the increasing challenges in our healthcare system. Approximately a third of all out-of-network claims may be subject to a state or federal balance billing law that prohibits a provider from balance billing the member for services covered under those respective laws. Given the appeals process for a provider is only 30 days from receipt of the initial determination under federal law, provider should quickly review all remittance advice for any remark codes that indicate the charges are covered by a federal or state balance billing law. Where this does not exist and where the remit indicates that the provider was out-of-network, providers should quickly assess these as well by calling the insurers for confirmation if those claims were subject to a such a law. If so, providers should quickly submit their appeal without balance billing the patient beyond the listed patient cost-share for regulatory compliance. When a balance billing law does not exist, then the provider should pursue their normal process for addressing appeals, denial management, and account receivable processes.
But how do you handle those new balance billing law appeals? First, know whether the charges are covered under a state or a federal law. This will determine jurisdiction and the process to be taken. It also helps determine what reimbursement methodology you should pursue. For example, if you’re charges are processed under the state laws of Texas, New York, Virginia, Georgia, or Alaska, you may be able to request reimbursement under usual and customary rates, but go to Nebraska, Maryland, Ohio, or Colorado, and your reimbursement may allow an insurer to base your reimbursement on Medicare or in-network contracted rates. Other states may have a payment standard range like Missouri and California. Under federal law there is no payment standards on how to pay the provider, but there are prohibited factors that can’t be used in negotiations. Providers and payers cannot utilize billed charges, usual and customary rates, percentage of billed charges or usual and customary rates, or public payer systems such as Medicare. Knowing these pitfalls will help in getting more successful negotiations. But it’s not all about using the right monetary arguments. It’s also about knowing how to make solid arguments. Many states and the federal law allow for arguments about good faith or bad faith negotiations that can be used by either side in arbitration, mediation, or a dispute resolution process. Providers and payers should both share their arguments about why payments are reasonable or unreasonable. For providers, the quickest way to lose arguments with a payer is sharing generic information about publications or specialty. Many providers are published. Many professional providers can use an office visit code despite different specialties. Payers need arguments about specific care and treatment to win these arguments. Even many regulations talk about that required specificity on the complexity or care of the patient. However, payers have to meet medical loss ratio requirements where the law requires them to pay a specific percentage of premiums on medical care. If you cannot balance bill, make sure to be prepared to show your in-network rates for transparency from other carriers in the state as both the high and low range for those same services. This will help further the arguments where balance billing laws are based on contracted rates or where both sides cannot use a prohibited factor.
Together, we will explore the methodologies on what works and what does not work today with balance billing and appeals management. This is an area that continues to evolve given the laws in place.