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Out of Network Billing


With healthcare providers evolving to empower consumers with more choices, along with interest in taking additional care of their health, employers are being influenced to offer less restrictive healthcare packages. Most healthcare plans allow members the flexibility to use providers of their choice. Due to this flexibility providers are benefitted in getting paid in high dollar claims are out-of-network. Most of the claims are paid at Reasonable and Customary result in greater plan cost for both the employer and the member.

Therefore, negotiation process begins to get fair reimbursement line by line review of the charges, along with most skilled medical negotiators reviewing appropriateness of services rendered.

The third party network or team then aggressively negotiates with non-network hospitals, physicians and ancillary healthcare providers to help reduce our clients' and their employees' healthcare expenses. These negotiations encompass a Reasonable and Customary review of the charge levels, as well as a review of the appropriateness of services rendered. Our medical review negotiation team is supported in the negotiation process by a variety of cost databases, claims utilization history databases and reference tools to substantiate their

According to health economist and management consultant, today's health providers need to focus on revenue cycle workflow because they will be caring for patients over the long term, not episodically. "That means looking horizontally at the value-chain of care, from unpaid encounters through the paid encounter administrative tasks. At the front end, the provider must capture and clarify the insurance and payment provisions for the patient.


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