Out Of Network Reimbursement Services

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Getting Started

Our team approach with our clients ensures that all relevant patient benefit information is gathered from the start, providers have the requisite forms to protect their rights and comply with all federal and state regulations, and relevant information is documented when verifying benefits. We provide our clients with proprietary documents for the patient intake process to protect your rights as a provider to pursue fair payment, including required Federal and State forms. We collaborate with your practice to obtain patient’s health benefit documentation, which is critical to craft strategies for maximizing payment and to understand the plan’s impact on the reimbursement and appeal process.  We ensure HIPAA compliance at every step of the way.  We provide the resources and expertise so that your practice can focus on patient care.

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Medical Necessity & GAP Authorizations

The challenges of obtaining authorizations can be time-consuming and overwhelming for providers’ staff, with long hold times and multiple follow-ups required. In many cases, insurance networks are inadequate for patients to utilize a network provider and the need for a GAP exception is required, an often underutilized and misunderstood strategy for maximizing reimbursements.  We have a track record of securing authorizations for medical necessity and GAP, as well as success in negotiating single case agreements for these complex surgeries.

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Medical Billing

Having handled claims for a wide range of out-of-network surgeons for over a decade, we have the unique advantage of knowing what triggers initial payment delays, underpayments or denials. Reviewing progress notes, operative reports and code selections, coupled with our understanding of CMS and payor-specific rules, enables us to helps our clients to avoid these triggers.

Recognizing that reimbursement strategies can vary depending on the payor, we work with our clients to implement a roadmap of best practices to avoid initial payment delays and to set up claims that will enhance our clients’ ability to maximize reimbursement.

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Insurance companies and third-party repricing entities are incentivized to minimize negotiation offers, which many times result in failed outcomes and wasted staff resources. The use of our extensive repository of historical payor payment data, insurance correspondence and plan documents creates the leverage we need to intelligently and persuasively negotiate a best offer for our clients.

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Comprehensive Appeals

The appeal process is becoming increasingly complex under ERISA, payor rules and plan documents, requiring an extensive knowledge base to successfully pursue payment through the appeal process.  CHRMS implements a multi-disciplinary approach to this process. We craft complex, substantive appeals on a claim-by-claim basis and ensure proper timeliness and exhaustion under patients’ health insurance plans; a critical component in ensuring our clients’ claims are positioned to succeed in maximizing reimbursement under ERISA, state regulations and other alternative pathways.

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Federal & State Surprise Bill Claims

With the enactment of the 2022 No Surprises Act and the virtual elimination of patient balance billing, the ability to determine the eligibility of a claim from the onset is critical to meeting time-sensitive deadlines and maximizing reimbursement from insurance companies.

The complexity of the regulations and processes has overwhelmed even the most informed in the out-of-network community, and has paralyzed many from properly pursuing reimbursements, where real opportunities exist for additional payment under a shortened revenue cycle.

Our depth of understanding these complex regulations and processes, especially the application of multiple claim pathways for a single date of service, is paramount to our success when utilizing independent dispute resolution under the NSA and state law regulations.

You can access the NSA Patient Notice and Consent form here.


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