Understanding how to effectively navigate the complex world of out-of-network billing can present a significant opportunity for surgical practices to optimize reimbursement from commercial insurance. Despite evolving tactics from insurers to delay, deny, or reduce reimbursements, and substantive regulatory changes adding layers of complexity to the billing and RCM process, opportunities to prosper exist. Here, we outline key opportunities for surgeons to practice as out-of-network providers and highlight how our comprehensive service offerings can empower practices to thrive in this complex and highly regulated reimbursement landscape.
1. Optimizing Reimbursements and Reducing Denial Rates
One of the most significant hurdles out-of-network providers face is the persistent under-reimbursement or high denial rates from commercial health insurance companies on medical claims submitted for surgical services rendered. It is no secret the commercial insurers are employing tactics to minimize payments to providers, leaving surgeons to bear the brunt of financial shortfalls. At CHRMS we bring together our expertise in coding, billing, ERISA, healthcare insurance and regulations all under one roof. Our team evaluates claims on a case-by-case basis ensuring accurate and strategic claims submission and consistent follow-up. We understand the patterns and practices insurance companies use to reduce payments and we employ proven methods to minimize denials and underpayments.
2. Empowering Staff to Focus on Patient Care
The administrative burden of managing out-of-network billing can lead to high turnover and burnout among staff. When personnel are stretched across multiple roles and lack the proper training or knowledge — the efficiency, accuracy and effectiveness of the billing processes can suffer. This can result in missed opportunities to maximize payment or eliminate claim denials due to avoidable errors. CHRMS offers a single-source approach beginning with pre-service authorizations/medical billing through appeals and filings under Federal and State Surprise bill laws. By outsourcing to a team of experts, you can ensure that your billing processes are strategically managed in a timely and effective manner, and practices are able to focus their resources on patient care.
3. Navigating the No Surprises Act (NSA) Process
The No Surprises Act (NSA) has introduced additional layers of complexity to the billing process, requiring extensive regulatory knowledge to navigate the Federal Independent Dispute Resolution (IDR) process after receipt of the initial payment or denial. Many billers lack the depth of knowledge to handle NSA claims appropriately, leading to dead-end appeals, or low reimbursement. At CHRMS, our team is well-versed in the timely handling of NSA negotiations and the federal independent dispute resolution (IDR) process. With over a decade of servicing out-of-network surgeons, we have acquired a comprehensive repository of historical payment data from payors in all surgical specialties across the U.S. Our goal is to protect providers’ rights to dispute under-reimbursed claims through the NSA or a state specific surprise bill law depending on various factors. CHRMS is proud to be one of the first in the industry to recognize the NSA impact on out-of-network surgeons and develop the necessary systems to effectively handle the complexities of the IDR process. Our team is committed to staying ahead of the regulatory changes impacting reimbursements and remain laser focused on leveraging technological advancements, such as AI, to streamline our operations.
4. Outsourcing Claim Management to Maximize Reimbursements
Effective claim management is crucial for maximizing reimbursements and ensuring financial stability. However, the complexities of out-of-network billing can overwhelm in-house staff, leading to delays and potential revenue loss. By outsourcing claim management to CHMRS, you can leverage our expertise and advanced technology to ensure timely and accurate processing of claims. This strategic approach not only maximizes reimbursements but also enables your staff to focus on patient care, improving overall operational efficiency and reducing administrative stress.
Our Unique Value Proposition
Our unique value proposition lies in offering a comprehensive, single-source solution that covers the entire spectrum of out-of-network billing services. We provide:
Outsourcing to a specialized team rather than a generic finance or billing organization means that your billing processes are managed by professionals with the right expertise in regulatory, insurance, surgical billing and RCM aspects that impact payment. CHRMS is dedicated to helping surgeons achieve financial stability so they can focus on providing excellent patient care. Contact us today to learn how we can transform your out-of-network billing experience.