Better Outcomes Are Still Possible through the Science of Out-of-Network Clean Claims Submission

US healthcare providers have been working under a fluctuating payment landscape. The out-of-network reimbursement picture has been shifting too. Payers make a large percentage of their profits by extending out-of-network benefits to their subscribers (aka, your patients) and by then persuading them not to use those same benefits. Even so, there are some significant opportunities to push back against carrier practices that run counter to your treatment protocols and the best outcomes for your patients.


Carriers Used to Act as Benevolent Dictators

Prior to 2010 and the US adoption of the PPACA, the healthcare industry was dominated by the large insurance companies, and it still is. Big insurance, though, was a benevolent dictator that raised premiums year-after-year at a double-digit rate, introduced the consumer-driven care concept to begin shifting additional financial responsibility to the patient, and managed their profitability through the attainment of a targeted medical loss ratio by denying coverage and applying pressure on in-network and out-of-network providers alike. While the system was weighted in the insurance companies’ favor, independent facilities ultimately were paid enough to earn an acceptable return because the system was based on private insurance HMO rates.


Carriers Now Create a Provider Conundrum

However, large health insurance carriers are now creating a conundrum for providers and every year they use the advantage of their size to increase the pressure. Large carriers know that the business of direct patient care is a big enough battle on its own. Rarely can providers serve their patients with excellence, run their practices with precision, and fight the battle with carriers. The large insurance carriers now routinely seek to influence or direct medical decisions. They purposefully reduce in-network and out-of-network ASC reimbursements under the cover of reducing overall healthcare costs. Large carriers continue to exert pressure on providers by consistently seeking to pin private insurance rates to Medicare reimbursement rates, even though Medicare cost is a function of the federal budget and the number of subscribers and has nothing to do with private healthcare costs.


But PPACA Also Creates Some Out-of-Network Opportunities

In common parlance, we often drop the Patient Protection aspect of the Affordable Care Act, but the patient protection part of the act did two very interesting and empowering things. It strengthened the patient’s right to choose and it strengthened the physician’s right to determine medical necessity. These two conditions help Contego to unlock the value of the ASC asset through the strategic application of out-of-network claims management, so ASCs can obtain better reimbursements in an environment where carriers are seeking to reduce them.


What Does Contego Do to Optimize Out-of-Network Reimbursements?

Contego is a private insurance reimbursement expert that specializes in driving revenue for out-of-network providers coupled with a command mastery of federal and state law that mitigates risk. Contego offers providers:

  • Predictive modeling advances reimbursements
  • Highly effective deductible and co-ins management
  • Expert application of the claims and appeals process
  • Pinpointed utilization of legal resources
  • Rigorous compliance with federal and state law
  • Stellar patient advocacy and education
  • Continual engagement with top healthcare attorneys