Melissa,
I'll give you an idea what changes we've made since our state (Washington) put their own Surprise Billing law into effect 1/1/2020 and we also are hospital based.
· For the few out-of-network payers we do have, we've made sure that the system holds patient balances while claims are out for processing/payment/denial.
· Ensure that the denial codes related to "out of network" drop the balances to review for staff, NOT just to a patient statement.
· Make sure your staff &/or your system alerts you in a timely manner to these payments/denials as you are "on the clock" for payment negotiations.
· Work backwards with your hospitals (ie, identify what networks in the area you do NOT participate in and whether they do or not) -- usually a smaller list that way AND when I've asked them to confirm/deny participation for 7 or 8 plans, I get a much more favorable response than going through 100's in a list (NOT that you do that, but trial/error from them approaching us in that manner).
· Reach out to those non-contracted payers to see if there is any way to work out either a participation agreement OR an out-of-network payment agreement (the ones that usually come by fax asking you to take a reduction anyway) by reminding them how much time/staff time/effort/costs it's going to take on their side to address these on a case-by-case basis as well (depending on your area, you may not have enough of these to make it worth your while).
· Make staff aware NOT to just take what is paid and do write-offs – if you do a number of these, you can create an "implied agreement of contract" for payments at the level they are making and they can hold you to that for future cases.
Obviously the issue you will have is for non-emergent cases and whether or not the patient had 72 hours advance notice for estimated costs, etc. – our law does not have that stipulation (means it applies regardless) so we're on the hook no matter what and rely on the above items to try and catch these. We've also spent the previous year knowing this was coming by trying to reduce the number of out-of-network plans we have to deal with – successful with some, not so much with others but they are far and few between.
Let me know if there's anything else I might be able to answer or help with, feel free to contact me directly as well
Michelle
Michelle R. Juette, CPC, RCC
Business Services Manager
Yakima Valley Radiology
(509) 895-0402 (direct, voice/mail)
(833) 520-5265 (secure fax)
mailto:mjuette@yakrad.com
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