Out-of-Network DRAFT

Out-of-Network (OON)

FlexPoint can help you achieve maximum reimbursement for Out-of-Network (OON) claims.

Issue

Insurers will do everything they can to minimize reimbursements to healthcare providers for OON claims. Insurers use 3rd party cost-containment vendors (e.g. MultiPlan) who are incentivized to maximize savings for the insurance plan by using:

Medicare benchmarking
Prospective inpatient claim review
Negotiation

Their playbook is to set up Medicare benchmarking allowance as a final OON payment for high-volume, lower-dollar claims. Their prospective inpatient claim reviews and negotiations focus on:

High-dollar billing errors and issues
Duplicate charges
Plan exclusionary denials

One insurer boasts on their website that their Medicare reference-based position results in 65% average savings for Out-of-Network claims.

Solution

FlexPoint identifies 100% of your underpaid Out-of-Network claims and generates additional reimbursement dollars on those claims. We maximize reimbursement by negotiating directly with the insurers and/or their 3rd party cost-containment vendors (e.g. MultiPlan). FlexPoint’s proprietary data warehouse enables us to negotiate with confidence.

Founded in 2010, FlexPoint provides clients throughout the United States with claims data that is more current and more precise than any other data product available in the market. Our data is irrefutable and can be used as concrete evidence in support of your organization’s position at the negotiating table.

Pre-Payment Recovery

“Negotiations”

On your behalf, FlexPoint will work directly with the insurer to investigate claims that have been adjudicated with reduced payment amounts (but prior to actual payment), have been placed on hold, or denied. FlexPoint strives to informally resolve issues on initial contact with the insurer whenever possible. Most claim issues can be remedied quickly by providing the insurer requested or additional information for denials related to timely filing, incomplete claim submissions, and contract / fee schedule disputes. If issues cannot be resolved informally, insurers normally offer two options:

An appeal process for resolving contractual disputes regarding post-service payment denials and payment disputes. Processes may vary due to state mandates or contract provisions.
For claim denials relating to claim coding and bundling edits, a healthcare provider may have the option to request binding external review through a Billing Dispute Administrator.

Post-Payment Recovery

“Appeals & Arbitration”

On your behalf, FlexPoint will file Appeals and/or submit for Arbitration any disputed claims that have not been fairly resolved through Pre-Payment Recovery efforts.

If an Appeal is unsuccessful, Arbitration may be used as a final resolution step. If an arbitration provision was placed in your healthcare provider agreement, the terms and conditions of that provision will apply. If your healthcare provider agreement does not include an arbitration provision, the appealing party prepares a Request for Dispute Resolution list and submits it to an independent 3rd party Alternative Dispute Resolution (ADR) service.

FlexPoint will handle the entire Appeal and Arbitration process.