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The out-of-network game: Science of the clean claim submission & art of the appeal

It sends patients running and creates headaches for providers — out-of-network policies have earned infamy as an extremely complex insurance landscape to navigate. But what if a correctly executed OON model is the key to maximum revenue and benefits?

A group of 30-plus executives, physicians and ASC administrators gathered to discuss the value of an OON provider at the Becker's 16th Annual Future of Spine + The Spine, Orthopedic and Pain Management-Driven ASC Conference in Chicago, June 15. Liam Hughes, president of Nashua, N.H.-based Contego Solutions, kicked off the roundtable discussion by asking who in the group was already participating in the OON environment. The majority of participants noted involvement with OON, with one person considering it.

Historically, the Employee Retirement Income Security Act of 1974 offered providers a straightforward path for success in the OON claims and appeals process. In 2010, the passage of the ACA complicated the game.

"Unfortunately, most healthcare providers are expected to do more work than they did last year, with increased administrative burden, and expect less financial return," Mr. Hughes said. "And most independent providers don't have the depth and breadth of knowledge, background, experience or resources to make the out-of-network play still work for them financially."

That's where Contego Solutions comes in. The company aims to help providers deliver the best patient outcomes and help patients utilize their insurance benefits. And OON is a way to achieve both. Despite the challenging prospect of OON, Mr. Hughes emphasized the immense opportunity it still provides.

Contego delivers a two-pronged approach: the "science of the clean claim submission" and the "art of the appeal." Mr. Hughes noted the claims process isn't rocket science, but it requires a dedicated team focused on the details. The appeals process, on the other hand, needs people who can piece data together in a "coherent, cogent narrative" that inspires a reimbursement event.

"In a perfect world, if you have a system of out-of-network claims and appeals that's built on ERISA and [ACA], that's all you need," said Mr. Hughes. But that's not usually how it plays out. "The only thing that can hold these insurance carriers accountable is the federal law."

Understand the laws and marketplace
Between 2017 and 2018, Contego has tracked shifts in the marketplace. ACA permits carriers to link OON reimbursement to Medicare rates. In January 2018, self-funded plans started acting more wisely regarding preferred provider organization plans.

"It really gets down to understanding [ACA] and self-employed groups' ability to reduce, diminish or prohibit benefits and proactively vet for that," Mr. Hughes cautioned. "The game has changed a little bit, but there's still huge opportunity out there."

Contego has also noticed a shift in summary plan document language. Plan administrators are required to provide participants with the Summary Plan Description (SPD), which is an overview of what a plan provides and how it operates. Before the ACA, providers had a legal right to access patients' SPDs. Since the health law's implementation, only the patient or patient's advocate has a legal right to receive the documentation.

In light of these SPD changes, Mr. Hughes recommended employing an internal legal team to interact directly with plan administrators. He asked the executive roundtable participants if any were currently dealing directly with plan administrators to drive revenue events. The administrator of a multispecialty ASC in the Southwest said they were, adding that they don't have to do many appeals because they acquire the SPD proactively.

"It's a lot of work, though," the ASC administrator said. "It's usually helpful before you go into surgery to know how the plan is going to pay." In response, Mr. Hughes said the administrator's organization was at the "tip of the spear" by proactively requesting the SPD, way ahead of most providers in the OON arena.

Contego just started proactively requesting the SPD at the beginning of 2018. When the company first started this practice, it took about eight days to acquire the SPD after reaching out to the patient. Today, Contego can complete the process, from SPD obtainment to the financial estimate, in about four days.

"It's really about alignment and about getting the systems in place to do it, but we've been doing it for about six months, and we put this plan in place with providers that we work with, with amazing success," Mr. Hughes said. "It allows you to make 100 percent of the shots that you take."

Make the complex understandable
Patient engagement is a critical aspect of OON success. Several leaders in the room shared their challenges with persuading patients to participate in OON.

"In our market, as soon as patients hear the words out-of-network, they scatter. So, we adjusted our script and how we approach the patients, and also base our cost estimates on one standard," said the administrator of an ASC in the Midwest. "So, how would you delicately approach that conversation?"

Mr. Hughes responded that Contego handles these conversations with patients carefully. "I went into this [effort] with the assumption that providers never want to get remotely close to this, and if patients hear out-of-network, they are going run for the hills. So, we have created the team, the system, the process, the script and the narrative, reinforced with training [to engage patients effectively]."

The CEO, president and anesthesiologist of a surgery center in the Midwest pressed further, asking how Contego actually convinces patients to participate in OON.

"We're really good at communicating that message to the patient." Contego helps make the "complex understandable," Mr. Hughes explained, presenting the advantages of going OON for patients through education of plan benefits.

The company dispatches an advocacy group to proactively work with the patient pre-surgically to procure the SPD. Contego is able to then effectively engage with the patient to collect deductibles.

How it works: The science of the clean claim submission and the art of the appeal
After the advocacy group has obtained the SPD from the patient, Contego conducts a forensic SPD analysis; screening for exclusionary criteria and understanding the reimbursement methodology. This analysis yields an on-target financial calculation of cost.

Contego began implementing this process since January and has reviewed the outcomes of about 200 cases. Here are the results:

  • $2,685 average increase in deductible collection for ASC utilization 
  • 18 percent increase in net revenue per medical event

Mr. Hughes then shared Contego's original claims and appeals process for a case involving a patient undergoing a laminectomy at an ASC:

  1. Contego submitted a claim for $27,550.
  2. Cigna allowed $800, paid $0.
  3. Contego procured SPD and structured an appeal for underpayment.
  4. Appeal was denied.
  5. Contego filed a complaint with State Department of Insurance and Department of Labor.
  6. Contego engaged with the plan administrator at patient's employer.
  7. Cigna requested opportunity to reprocess the claim.
  8. $27,550 claim re-submitted.
  9. Cigna allowed $24,044.
  10. Provider received reimbursement of $14,844.
  11. Contego filed an appeal and re-engaged plan administrator.
  12. Provider received additional reimbursement of $4,821.
  13. Total reimbursement to provider was $19,665, reflecting 71 percent of the initial claim submission.

"Here's the bad news: that took about 16 months," said Mr. Hughes. "So how have we made this tighter?"

The following claims and appeal timeline for a patient undergoing an ACL repair reflects Contego's current process:

  1. Advocacy group works with patient proactively to procure the SPD.
  2. Methodology in SPD supports usual, customary and reasonable reimbursement.
  3. Contego predicts a $12,000 reimbursement for the procedure.
  4. Contego works with the patient to collect deductible.
  5. Contego submits claim.
  6. Provider receives reimbursement of $7,912 in 22 days.
  7. Appeal submitted.
  8. Provider receives an additional $4,188 reimbursement seven days later.
  9. Provider receives $15,100 comprehensive reimbursement in less than 30 days.

"We've been able to get a 16-month process down to 30 days," Mr. Hughes said. "If you're in the OON game, I very much urge you to replicate this process, because it very much works."


Learn more about Contego Solutions, here.

More articles on coding, billing and collections:
Billing tip of the day: Remember these 3 rules when billing Medicare for IOLs
Maximize your 2018 reimbursements: Know your health plans, know your market, and stay on top of trends
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