Becker's ASC Review

21 Executive Briefing: Coding, Billing & Collections I n a post-reform era, out-of-network payments remain one of the last fron- tiers for ASCs to reap higher reim- bursements and increase their profit mar- gins. However, an alarmingly high number of ASC administrators are unaware of how or choose not to take advantage of OON reimbursements, according to John Bartos, CEO of Collect Rx, a revenue en- hancement firm specializing in maximiz- ing OON reimbursements. "If you look at the healthcare landscape today, there aren't a lot of opportunities to improve your reimbursement rates," says Mr. Bartos. "Your in-network rates are what they are — there's very little opportu- nity to increase those, and there is literally no opportunity to increase your Medicare and Medicaid rates. OON remains the one of the last frontiers to get higher re- imbursements and raise profit margins." OON reimbursements are significantly higher than in-network reimbursements. While taking advantage of the potential for increased payments through OON can be beneficial for an ASC's bottom line, there are challenges involved. For one thing, payers employ various tactics to attempt to reduce OON payments. "There are a number of companies out there that specialize in helping payers reduce reimbursements on OON bills," says Mr. Bartos. "As many members of our team used to work for these companies, we are well-versed in the tactics they use and how to deal with them." Payers often attempt to negotiate single case rate agreements or use usual, cus- tomary and reasonable rate re-pricing. Insurance companies will attempt to ne- gotiate a settlement with providers for a large discount on a bill after services are provided but before payments are made. UCR re-pricing happens when the insur- ance company lowers the UCR payment close to Medicare rates. Challenges imposed by payers are not the only obstacles for ASCs to collect higher OON reimbursements. Many ASC administrators believe they don't need to negotiate pre-payment rate agreements or pursue post-payment appeals. The reimbursement increases are significant and warrant the extra work involved in obtaining higher rates, according to Mr. Bartos. There are five common myths regarding OON payments that ASC administrators should be aware of, according to Mr. Bar- tos. Myth 1: The days of OON are over. This belief is heard among some ASC admin- istrators, but it is false. "We believe it should be a part of most facilities' reimbursement strategies de- spite any hits around the edges," says Mr. Bartos. For one thing, PPO enrollment has more than doubled while HMO's have declined, according to Mr. Bartos. He believes the number of insureds seeking OON care will rise as the reach of the Afford- able Care Act increases and the growth in narrow networks accelerates. Narrow networks are excluding many high visibil- ity providers who have been in-network traditionally, further increasing the merits of pursuing enhanced OON reimburse- ments, according to Bartos. The rise of the high-deductible health plan means individuals are shouldering a greater proportion of the cost of their care. Along with this comes the demand for more choice. People want OON bene- fits in their health plans so they can have a greater say in the providers they see and where they go for surgery. Myth 2: Being 100 percent in-network maximizes reimbursement. While rates differ by case and geography, for the vast majority of cases, OON reimbursement is higher than in-network cases, which is why insurances companies actively seek to cut it down, according to Mr. Bartos. "That said, we don't recommend going 100 percent OON," he says. Instead, ASCs should take a hybrid approach — meaning some of the ASC's business should be in- network and some should be OON, de- pending on its particular situation. When developing an OON strategy, it is important for ASCs to take numerous factors into account, including payer mix, employer mix, relative market share and possible volume issues. To deter- mine the best path to pursue when con- sidering going OON, Mr. Bartos recom- mends identifying the number of cases and reimbursement level for the most 5 Out-of-Network Myths — Debunked By Tamara Rosin Sponsored by John Bartos

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