Empire Self-Insured Federal Government Policy – In Network Exception

This was a 2013 case wherein the provider was able to obtain an in-network exception, but did not negotiate prior to surgery.  The complex surgery involved two co-surgeons and a physician assistant.  Billed charges totaled $412,176 for the co-surgeons, and $17,800 for the physician assistant.  The initial payment from the insurance company was $38,000 collectively for the co-surgeons and $1,680 for the physician assistant.  The provider filed a first level appeal before turning the case over to CH Revenue Management Solutions.  CH Revenue Management Solutions was able to obtain an additional payment of $394,000 reflecting payment on all dates of service for this patient.

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