How & Why We Negotiate Medical Claims

It is an all too common occurrence: a motorist is seriously injured in a car accident and requires emergent treatment. According to the National Safety Council, nearly 6,300 people sustain serious injuries every day in the U.S. due to motor vehicle accidents1. Most of these people are immediately transported to the nearest hospital for care. Checking to see whether the doctor or hospital is “in-network” is a secondary concern. Everyone’s priority is saving the patient’s life and restoring function to the injured body.

After the patient is stabilized or even long after the patient has been discharged insurance and financial problems begin to surface. The on call surgeon could be a “non-participating provider” for that patient’s insurance plan and might balance bill the patient. The radiologist, emergency physician, anesthesiologist, hospital, ambulance, and all other providers who are involved with that patient’s care may be “out of network.” Each of these providers could file a separate claim, which further complicates the situation. Depending on the patient’s certificate of coverage, their insurance may not fully cover the cost of out of network care, or they may dispute the definition of what constitutes an emergency.

Some insurance companies pay out of network providers at a “reasonable and customary” rate, or they may pay out of network claims based on a percentage of Medicare. Even so, the member is typically not protected from balance billing, unless the state has enacted laws to prevent such scenarios (such as New York’s “surprise bill” law which went into effect last year2). In these cases, the member may owe thousands of dollars to several out of network providers, and the financial distress can become overwhelming to the patient and his or her family.

Nokomis has spared many patients from financial duress by negotiating single case agreements with out of network providers, whereby the provider agrees to accept payment in full and not balance bill the member, and the insurance company often ends up paying less than they otherwise would pay in the absence of an agreement. We recently negotiated a set of eleven claims for a client, all from the same surgeon, and obtained secure discounts of over 65%, resulting in savings of over $1 million to the plan and the members. These patients were held financially harmless, and no longer had to deal with the uncertainty of several hundred thousand dollars’ worth of debt.

These eleven claims were truly amazing for the size of the charges, and unfortunately, are not uncommon. One of the claims was for $49,935, which was more than 30 times the Medicare allowed amount for the procedure codes. The insurance company was prepared to pay this claim at “reasonable and customary” charges, which would have left the member with a very large debt to the surgeon. The insurance company asked us to attempt negotiations with the provider’s office. Through the tactical use of medical coding knowledge, Medicare rates, cost to charge ratios, comparative charge information, and negotiation skills, we successfully achieved discounts totaling $45,979 and obtained sign off from the provider to not balance bill the patient. The health plan paid $3,956 on the claim, which was much less than they otherwise would have paid, and the patient had no further out of pocket expense.

Medical claims can have a significant impact on patients and providers. Claims that are not being reviewed or negotiated for discounted rates can leave health plans, self-funded employers, and consumers alike in a state of financial distress. Nokomis assists in managing these costs and ensures that no claim goes unchecked. By using our sophisticated claim review software and negotiating on behalf of our clients we can generate significant savings and improve payment integrity.

Nokomis is a leading national provider of claim review services. We generate sustained claim savings for payors through the use of our proprietary ClaimWiseTM review engine along with our highly experienced certified coders, analysts, and clinicians. To learn more about how Nokomis can enhance your services and to inquire about a complimentary claims analysis, contact us here.

1 http://www.newsweek.com/us-traffic-deaths-injuries-and-related-costs-2015-363602
2 http://www.dfs.ny.gov/consumer/hprotection.html