Bill Klaproth (Host): This is an AAOMS On The Go podcast. I'm Bill Klaproth. Joining us today is Tom Force, President of The Patriot Group, a full service revenue cycle company and owner of healthcare law firm, The Force Law Firm PC. Tom is here to discuss insurance considerations for the OMS for the effective handling of out of network claims.

Tom is a licensed attorney and former U.S. Marine. He has been working in the healthcare revenue cycle for the better part of the past 30 years. Tom, it is a pleasure to talk with you. Thank you so much for your time.

Tom Force, Esq.: Bill, thanks for the invite. Great to be here as well.

Host: Absolutely. So let's jump right into this. What rights does an OMS have as an out of network provider? For example, what is balancing billing and should an OMS balance bill an out of network patient?

Tom Force, Esq.: Good question. Balanced billing basically is the difference between the charge and all payments received from the insurance company and the patient. The reason why balanced billing is a big deal is because many insurance companies and their third party administrators, audit OMS providers who are out of network to determine if the OMS provider is routinely waiving patient cost share, such as deductibles, coinsurance, and the balanced bill.

So these insurers, they refer to these audits as fee forgiveness audits. They're very common right now. I would say Cigna is the one that's most aggressive, although I've seen United, the Blue Cross entities, and some other carriers do these as well. So it's important that the OMS provider do not routinely waive cost share.

And by the way, that's the same standard for a in network provider too. You don't want to waive, routinely waive patient cost share. I'm talking about deductibles and co-insurances, especially if you're in network, by the way, for Medicare claims; never do that. Waiving balances, at least according to the insurance company, is deemed to be insurance fraud.

So if you're going to waive balances, it should be rarely done, and it should be based on a financial hardship reason, such that the patient cannot afford financially to pay their cost share. If you're going to do that, you need to have a written financial hardship policy.

It needs to be reasonable and you need to have supporting documents such as tax records and unemployment stubs and things of that nature. So, again the point here, is these insurance carriers who do audits are looking for routine waiver of cost share. I know we're talking about out of network providers. It applies to in network providers as well, Bill.

Host: Okay, so then, what does it mean if the patient assigns benefits, and where does the payment go if they do, and can an OMS request the patient to reassign benefits?

Tom Force, Esq.: Yeah, so, here's the issue particularly with out of network. If you're out of network, especially with the Blue Cross companies, you gotta expect that your claim payments are going to go to the patient. So you need to be prepared for that and there's a lot of things you can do up front as far as making sure the patients are aware which carriers are going to send checks to the patients.

And let me explain to you why they do that and it relates to assignment of benefit. Under the law, an assignment of benefit basically means between a patient and a doctor, that the doctor stands in the shoes legally for the patient. In other words, the doctor is the patient legally, and that means the doctor can send medical claims, can do appeals, can file regulatory complaints.

Problem in the out of network world is the carriers are pretty sneaky, they've figured out that they can include what they refer to as anti-assignment clauses in their policies and health plans, and those provisions mean that the insurance carrier will not accept an assignment of benefit between a doctor and a patient.

And that's the problem. When there's an anti-assignment clause in a plan or a policy, the check will go to the patient because the assignment between the doctor and the patient is not enforceable under that plan. That's the reason why checks go to patients. And unfortunately, there's really nothing you can do about that.

If there's an anti-assignment provision in a plan; that check is going to the patient. What you can do, though, is make sure that you educate the patient on how to return the check. I usually get my clients that we do medical billing for, I get them to have the patient sign a check to patient form and a strong financial agreement.

And I give them instructions. I actually think giving them a self addressed stamped envelope is kind of a smart idea too. Bill, so that's the problem with out of network assignment a benefit issue.

Host: Yeah, so you really need to educate the patient then. So then what should a OMS, who is out of network, with the medical plan do when a payment denial or EOB goes to the patient and they haven't properly educated them?

Tom Force, Esq.: Well, hopefully they're listening to this podcast and and they'll be properly educated. I mean the first thing you need to do is make sure there's a strong financial agreement so that the patient is signing that they're responsible for their ordinary cost share, deductible, co-insurance. If they're out of network, the balanced bill amount, difference between charge and payment, and that they're responsible within a certain time period, maybe 10 business days to return the check.

And if they don't return a check I usually throw in 3 percent interest accrued monthly and that they're responsible for full charges. So, if you have all of those things usually what I do particularly our company that does medical billing, you have to be aggressive and contact the patient immediately.

We call them, we email them. And as an aside, if you want to email patients, you need to have an email consent form where the patient acknowledges that you can communicate with the patient by email, it could be revoked at any time, and they need to include their email address. We email them, we call them, particularly around the holidays.

You gotta be, you know, when a patient gets a check around the holidays, you know, it's very, very difficult for the patient. They'll cash the check and you'll never see the money again. So you have to be aggressive. You have to do all those things pre-service and you have to be aggressive.

Now, if you do all those things and the patient still doesn't return the check to the practice. You need to put them in collections or file a lawsuit against them. What I've done for smaller claims under 5,000, I've actually filed small claims actions against the patients which is something the OMS provider can do without an attorney.

And the cost is nominal. It's like maybe $50 in their jurisdiction. You can do it online. However, you have to show up when there's a court date. And I would say that most of those small claims that I filed for clients out of maybe 10 that I filed seven settled before the trial date.

So that's a nice little technique that most OMS providers are not aware of that can help them with check to patients.

Host: Absolutely. So, bottom line then, Tom, patients who keep checks should be pursued to the fullest extent of the law for full charges. Is that right?

Tom Force, Esq.: A hundred percent, Bill, a hundred percent.

Host: Absolutely. So let me ask you this, OMSs are reporting their dental plans are requiring them to file medical insurance claims for services not covered by medical for the purpose of denial before the dental will consider payment. So why is this happening more frequently and how can an OMS avoid having to bill for a denial?

Tom Force, Esq.: Well, it's because of coordination of benefits in the plans. I actually did a recent webinar on this I think for the association for about an hour. We can speak for an hour about this issue. It's very complicated. The bottom line is this; the medical plan and the dental plan both have coordination of benefit provisions.

And in those provisions, they basically say that their policy is secondary to any other policy that may exist for the member. And they both have these plans. So what's happening is before the dental will pay, they don't want to pay a claim and then find out that there's a medical plan, particularly with surgeries, oral surgeries and then they have to do a refund, which costs them money, time, and effort. So what they're doing is they're saying, listen, before we pay these claims, file the claim with your medical. And, to be honest with you, I don't really see the problem with that. Just file a claim with the medical. Within 30 days, you'll get a denial.

When you submit the claim, submit the claim with a denial and you shouldn't have a problem getting paid. The problem with coordination of benefits is, frankly, and I've had this issue before, when both plans deny and say the other's primary. Then what you have to do is you try to get the plan from your patient and review the coordination of benefit provisions side by side, and then you might have to appeal. Generally, the surgeries are covered by the medical plan, and the traditional dentals, the profis, and the crowns, etc., are covered by dental. It does get complicated when you have kind of hybrid surgeries that are covered by dental and medical.

But I would say that it's not a bad idea to bill the medical insurance first, get that denial, and bill it to dental, if that's what the carrier is requiring. And Bill, what I try to do, particularly our company that that does medical billing, the insurance companies create these obstacles.

I jump through the obstacles to the extent possible. I play their game. You know, if they don't like my assignment of benefit form, they want their form. I send them their form. That's why, if you're out of network, it's so important, the front end, to make sure, and we'll talk about workflow maybe in a little while, but it's important to do. There's a lot more work and a lot more forms for the patient to sign when they're out of network as opposed to in network, Bill.

Host: There's so many obstacles like you said and what you do is you help the OMS, you jump through those obstacles for the OMS. These people just want to be oral surgeons and help people. There's so much to know when it comes to the insurance side. Oh my goodness. It's crazy. So you were mentioning out of network flow. So what is an effective out of network flow?

Tom Force, Esq.: Okay, so, if a practice is in network, they're not prepared to be out of network, frankly. They have to educate themselves because of what you just said. It's not just obstacles. Being out of network, there's, there's significant compliant risk. Not just the audits that we spoke about. We were talking about fee forgiveness audits. There's a lot of things you have to understand. Even the onset of the new federal No Surprise Act. That's something that passed last year. And if you're an out of network oral surgeon, and doing a procedure at an in network facility, you need to know that the No Surprise Act applies and you can't bill the patient more than in network cost share.

These are things that an in network provider would not know. And many times the mistakes I believe that, the in network provider makes when they transition to out of network; is they hire a billing company that only understands in network. And that's where they get themselves in trouble. And, Bill, I think I mentioned to you that I have a law firm that defends audits as well.

And we see a lot of in network providers that make those kinds of mistakes. And that's a tough way to learn from your mistakes. It's really tough to learn by making a mistake and having to pay significant money in an audit. So with respect to out of network workflow, we're talking about how to set up a workflow that's going to generate revenue for the practice, but also keep the practice safe, and ensuring that the claims payments come in at the same time rate as let's say, an in network claim.

So in my opinion, there's really three components of this. All right. Number one is pre-service, making sure you have the proper forms and I'd be happy for the audience if they to email me or the association, I would provide forms that I think are necessary.

You want to have an assignment of benefit form. You want to have a designation of authorized representative form, and most of the carriers have carrier specific forms. For example, UnitedHealthcare. If you Google UnitedHealthcare DOR form, you'll find their form. So you want to have a check to patient form. We've discussed that. That gives instructions to the patient, and maybe provides a self addressed stamped envelope if they get checks. You want to verify benefits. Very important. Oh, by the way, on the forms, you want to have a good financial agreement for sure, and probably a disclosure, disclosing that you're out of network to the patient.

I think that would be important. On the verification of benefit sides, out of network provider needs to understand, unlike in network, where you're looking at sometimes just $50 copays or $10 copays, it's not uncommon to have a 50 percent coinsurance and a $5000 deductible, which means you think there's out of network coverage, but it's really phantom coverage.

It really doesn't exist because the cost share is very, very high. So verifying out of network benefits is so important, much more important than in-network. And then you need to obtain plan documents. I have a form that I have patients sign called the SPD Plan Document Authorization Form.

And I get plans for every single out of network client that we bill for. And I keep a spreadsheet of all the plans. It's important to understand how that plan allows out of network. And I don't like trusting the carrier because they're not always truthful. So let's say you have a $5,000 deductible that's unsatisfied and you're doing a surgery.

You want to collect some of that upfront. You collect it as an estimate toward their deductible. But not as payment in full because you'll be in that fee forgiveness audit category that we already discussed. So, I mean, there's a lot of, I would say, verifying benefits, having the right forms, pre-service stuff.

That's number one. Number two is, you have to have good follow up, very effective follow up and quick follow up because sometimes, especially with Blue Cross plans, the checks go to the patient. So once you get the payment, component two is you need to evaluate. It's not like in network, Bill.

In network, the payment comes in, you contractually write off the balance. You're getting the fee schedule amount. You're billing for maybe a copay or deductible. For out of network, there's an additional evaluation. Did the payment match the plan benefits? In other words, let's say for an out of network plan, the plan is a reasonable and customary plan, which is basically a good reimbursement plan and the insurance company is allowing at 110 percent of Medicare.

You need to evaluate that and you need to be able to call the carrier up. And unlike in network, you can enter into case specific agreements, settlement agreements on cases which you should absolutely do. Every time there's a payment, you make sure you call the carrier, try to open a negotiation.

And if you have the plan or you know what the plan allows and they're allowing the plan incorrectly, in other words, it's a low payment; you need to appeal that. So there's a lot more work that goes into out of network, but it could be very, very beneficial because a surgery claim on a UCR claim, on an oral surgery claim let's say the rate differential is unbelievable. I mean, an in network surgery might pay $350, $400. You can get $15,000, $20,000 on an out of network basis. So all of the work is worth it because what you're trying to do is you're trying to find the golden nuggets, the plans that allow well, and you don't need every plan out of network to be allowed well.

If you find a 2 or 3 out of 10, that can make up for all the other claims. In network, you're going to get a lot of volume because you're in network, but you're going to get low payments. Out of network, find those 2 or 3 out of 10 and maximize the revenue for them. So that's 2.

Number 3 is like, I kind of mentioned it already. Appeal the low payments, open negotiations. Appeal non-covered line items. You get a lot more denials out of network than in network. And you need to make sure you appeal them. Two levels of appeal on fully insured plans that are insurance policies, file complaints with regulators. For self funded plans, it's Department of Labor, you can file complaints.

And if there are medical judgment denials, you can file external appeals. Bill, I'm sure that you realize there's a lot to know when you're out of network and that's why you need to have an expert help you transition. That's the point.

Host: Oof, I was going to say, there's so much to know and a simple, honest mistake can cost the OMS money, right?

Tom Force, Esq.: Yeah, but if it's done right, they can make significant money. So that's the balancing act. And that's how I'd like to close. I think what's important here is to understand that while out of network claims and workflow can generate significantly more money than in network. Because some of these plans will allow 40, 50 times what an in network rate will be.

Right. But there's a lot of obstacles and compliance pitfalls. So my suggestion would be hire an expert to help you with the transition. If you have an house billing company, have them get educated so that they understand all the nuances of a transition to out of network. If you have a medical billing company, find out how many out of network practices they bill for and make sure they're educated and they understand the process. At the end of the day, I would highly recommend practices that are in network to consider out of network on plans that their fee schedules are very low, they're allowing below Medicare rates or, or even Medicaid rates, consider possibly going out of network with those plans.

You don't have to go out of network with every plan. A lot of my clients, for example, Bill on Blue Cross. Checks go to patient. They don't want the aggravation. They go in network with Blue Cross, but they're out with everyone else. And maybe they're in network with Medicare. So that's what I would recommend to the out of network OMS provider.

Host: So by working with someone like you, really doing things right, doing all the paperwork, all the things that you described could be very lucrative, especially because you're looking for the golden nugget, as you put it. Is that right?

Tom Force, Esq.: A hundred percent, but I'm not saying they can't do it themselves. They can. I'm only recommending that in order to transition, even if you're going to do only one or two payers, you need to hire someone like me or have your staff become educated and take training classes on the out of network workflow because if you can master it, Bill, you're right. It's very lucrative. But you have to navigate through the obstacles and understand the pitfalls.

Host: Well, this has been really informative, Tom. Thank you so much for spending some time with us. As we wrap up, anything else you want to add as we close the conversation?

Tom Force, Esq.: I will reiterate what I just said. Again, I recommend out of network for certain payers, especially ones where the fee schedules are low, but just be careful. That's my recommendation. Be careful. There is a lot of pitfalls here. And if, you're going to do it, make sure you're educated, you understand the pitfalls, and Bill, I would also recommend that for anyone out there, any provider that's thinking about transitioning, take a health plan, one health plan that's under reimbursing you on a fee schedule. And maybe just pick one and start with one practice. All right. One payer rather. And see how that works and that's a good way to start. Don't transition. There are practices that say, oh, you know what, I want to transition to all payers.

Keep in mind also, Bill, I didn't mention this, but if you're going to transition to out of network you have to first terminate your in network contracts. And I can't tell you how many practices forget to do that. And then, they continue to get paid on an in network basis. So you have to terminate those agreements in writing.

You should probably have a copy of your contract. Make sure that the determination goes to the correct party under the contract. There's usually 30 to 60 day notification provisions as well. And I really hope this has been educational for the OMS provider. And I wish everyone in the audience that's transitioning to out of network, good luck.

Host: Right. Absolutely. Well, this has been very educational and informative. Tom, thank you so much for your time. This has really been great. Thanks again.

Tom Force, Esq.: It was my pleasure.

Host: And once again, that's Tom Force and for more information, the AAOMS website offers practice resources to help its members navigate coding and reimbursement issues. Visit aaoms.org/practiceresources for more information. And if you enjoyed this podcast, please share it on your social media and make sure you subscribe so you don't miss an episode.

Thanks for listening.