Unlocking the Mystery of Out-of-Network Denials:
A Must-Read for Providers In-Network!
What is “Out of Network”?
In the complex landscape of healthcare, the term “Out of Network” refers to healthcare providers or facilities that do not have a contract with a particular health insurance plan. When a patient seeks medical services from a provider outside the network covered by their insurance plan, it triggers an “Out of Network” scenario.
Explore ABC‘s Follow-up on a 2-Year-Old Claims worth $28K and gain insights into how insurances navigate the world of out-of-network denials.
If a provider is in-network with an insurance plan but experiences claim denials, it can be a challenging situation. Errors by the insurance company during claims processing, such as data entry mistakes, can lead to denials. Providers should regularly reconcile their submitted claims with insurance statements.
Provider (Biller)-Payer Communication: Open communication with the insurance company can help clarify issues and resolve denials. Establishing a point of contact within the insurer’s provider relations department may be beneficial.
Persistence Pays Off: Undeterred by the initial denials, our team embarked on a diligent follow-up journey. Over two years, we invested considerable time and effort into resolving these claims.
Frequent Calling: The ABC team spent 90 hours making persistent calls to Ambetter.
Email Correspondence: We started regular email follow-ups with provider relations, investing 10 hours in written communication.
Reconsideration Process: we submitted Reconsideration requests for all 80 denied claims, involving 22 hours of meticulous attention.
Positive Results: Starting from February 3, 2023, through continuous email follow-ups with Ambetter provider relations, we began receiving payments. Ambetter has thus far reimbursed us with $12,952.04.
Summary of Efforts:
- Time Invested: 2 years
- Total Hours: 122 hours
- Calling: 90 hours
- Email: 10 hours
- Reconsideration: 22 hours
- Total amount collected: $12,952.04
Key Takeaway: Our commitment to client care extends beyond providing services to navigating the complexities of insurance claims. By staying persistent and leveraging various communication channels, we’ve successfully turned around a significant number of initially denied claims.
Revolutionizing Denial and AR Management: Maximizing Reimbursements for Your Practice!
In the medical billing world, billers often adjust claims and move forward after out-of-network denials. At ABC, we go above and beyond to explore every avenue with insurance providers, giving your claims the attention they deserve. Denial and AR management is crucial in medical billing, requiring careful examination of unpaid claims and strategic appeals for rejected ones. Our team at ABC is well-prepared to identify the underlying causes of expensive denials, as it necessitates extensive expertise and timely implementation.
At ABC, our experts can efficiently handle denials and ARs, ensuring quick and effective resolutions to minimize reimbursement delays. Regain control over your denials and speed up reimbursement with our Denial Management team. Trust ABC to navigate the complexities and optimize your practice’s financial health!
Raja Chandra
Raja Chandra is the founder & president of Apple Billing and credentialing, a medical billing and credentialing company. He has a bachelor's degree in bio-medical engineering and has been working in medical billing and healthcare management since 2003.