Meredith Monteleone (Host): Hi, Tom. Good afternoon.

Thomas J. Force: Good afternoon, Meredith. Thanks for having me.

Host: Yeah. Thank you so much for joining me today. Can you give us a little bit of background on yourself and your company?

Thomas J. Force: Well, I'm the owner of Patriot Group. We're a full service revenue cycle company. We do medical billing, aged receivable followup, appeals, everything revenue cycle. I'm an attorney. I'm also the owner of the Force Law Firm. Our firm focuses on healthcare, particularly audits against practices. We basically fight with insurance companies all day in a medical claim world. I'm also a former Marine and I've been doing this far too long to be honest with you, over 30 years. My focus is healthcare, even when I was a lawyer, and out-of-network medical claims.

Host: All right. Excellent. So, give us a little update. What is the current state of out-of-network medical claims in the United States today?

Thomas J. Force: All right. Unfortunately, the last three years, you've seen a decline in revenue if you're an out-of-network provider, significant decline in revenue, which makes our job all the more difficult, to be honest with you. However, it's still very, very profitable to be out-of-network. And, hopefully, we'll talk a little bit about that today.

So, the state is you're seeing a decline in revenue and an uptick in audits by insurance companies and their special investigation units against out-of-network medical providers. That's where we are right now. And that's why this presentation, this discussion is so important.

Host: Yeah. That's actually kind of scary too, right? Walk us through it. How does one create an effective and proven out-of-network workflow to ensure maximum out-of-network reimbursement? Is it even possible?

Thomas J. Force: Yeah. Well, let me tell you why medical providers that are out-of-network fail. First of all, they use in-network billing companies that are familiar with in-network protocols. And those billing companies cannot possibly be effective. Many times, if they're doing in-network billing, their in-network billers don't really understand the complexities of out-of-network.

The good news is, although it's very labor intensive, it's not that difficult. The first thing is the vetting process. It's extremely important to vet out-of-network claims. Why is that, you might ask? Well, in-network, you're dealing with deductibles of $100 to $500. Office visits are just co-pays, $20 to $30, maybe $50, and very small coinsurance is 10% or 20%. Out-of-network, it's not uncommon to have an out-of-network deductible in the $10,000 range, 50% co-insurance. Those type of plans are what we call phantom coverage. You think, or the provider thinks, that, "Hey, I got out-of-network coverage here," but you really don't. Because with a $25,000 deductible and a 50% co-insurance, and a plan that allows at a Medicare rate, you're never going to get paid.

So, the vetting process is very important. But not just finding out about out-of-network deductibles and co-insurances, and out-of-pocket max, you need to train your people to find out how that plan allows out-of-network. You know, there's basically four types of methodologies, right? You have the plans that allow at some sort of internal fee schedule, almost like an in-network rate. You have the plans that allow at a percentage of Medicare, 110%, 200%. Those are not good for us. Then, you have the plans that allow at a reasonable and customary, or based on prevailing rate or average charges. Those are really good plans for us. Those are the plans we're looking for. And then, you have a discretionary plan that's either one of these methodologies, or the lesser of, or the greater of. So, you need to do a better job in the vetting process, number one.

The other thing that I think is important is don't just rely upon your vetting process. The first component of an effective out-of-network workflow is vetting. But you also have to request the plan document. very important, and you don't request it from the insurance plan, from the employer. I use a summary plan description request form, very simple form with the ID card. And you want to get that plan. Why do you want the plan? Well, first of all, that plan is going to absolutely tell you how out-of-network benefits are allowed. It's usually in the definition or glossary section of the plan. It's also going to tell you information like the definition of medical necessity or experimental in case you get denied. It's going to give you protocols on appeals, how many appeals. So, it's really important to do that.

The second component is and frankly why we charge more as a company for out-of-network providers than in-network is once the claim is paid, there's a lot to do. There's an analysis of the claim once it's paid. That's the second component. If you're in-network, Meredith, if the claim is paid as you know, we contractually write off the balance, we bill the patient. Easy peasy stuff, right? Out-of-network, when the claim is paid, that's when the fun starts. What I usually do is, obviously, you need to make sure that every line item is paid. And if it's not, you appeal it. But you need to evaluate. Let's assume for this example that we're talking about here that every CPT code was allowed. I compare the allowed amount to Medicare. Medicare is the floor, not the ceiling. And if the allowed amount is below or at a Medicare or maybe two times Medicare, my people call and they open a negotiation or they try to get that claim sent for reprocessing at a higher rate. That's the first thing we do. So, you have to analyze and come up with a game plan. What is your game plan? Sometimes out-of-network, particularly Blue Cross, Blue Cross checks go to patients, right? So, your game plan may be, "Hey, I need to go after the patient and get the check." You might also say, "I need to get the check, but I also need to send a reconsideration. It's a low payment. And by the way, one claim is denied for inclusive that shouldn't be." You could have three or four game plans on one claim. That's what most providers don't understand. That's why out-of-network is so difficult. You're fighting to get the right rate. Nine times out of ten, they're not going to pay you the right rate on the first EOB, as you know, Meredith. They're not going to do that. You have to fight them. You have to appeal them.

And then, finally, so we talked about vetting, how important it is, getting the plan document. We talked about coming up with a game plan once the claim is paid, doing reconsiderations, appeals, opening negotiations with the likes of Multiplan and MARS and whatnot.

The third thing is actually once you get the plan, that's when you can finally determine how that plan truly allows. Don't take the insurance company's word for it. Many times they tell me a plan is 110% of Medicare, and I find out it's a reasonable and customary plan. And you're going to need that plan to do an effective appeal.

There's a lot of steps in our network. I do think if you're aggressive, obviously, Meredith, you need to be aggressive because checks are going to patients sometimes. Your followups should be more aggressive. Maybe at 10 days, not 20 days, like in-network. But you should be able to get payment at the same rate, time period, as an in-network if you're aggressive.

The other thing about out-of-network that's really important is, unlike in-network, where you have to get every claim paid and there's a lot of volume, you know, and the payments are low, you get two UCR claims paid out of 10 at 60-70% of charges. It'll take you probably 30 in-network claims to recover that kind of revenue. That's why out-of-network is so important and it's still very profitable.

Host: That's excellent. So, just backtracking for a minute to how the plans allow, right? So, we know the Medicare plans are not necessarily ideal. So, how would a provider kind of seek out those good UCR and R&C plans in your opinion? Is there a way to do it to really kind of hone in on those particular types of plans?

Thomas J. Force: That's a good question. You have to develop a database of plans. Like right now, I have like 4,000 plans all across the country. I have them on a spreadsheet. When I send out a claim, I'm always requesting the plan document from the employer, not the insurance company, right? So, I'm always doing that. When I get a response back, I have an SPD person that will evaluate, put it on a spreadsheet for me. And also my staff knows when I get a high payment, I put that on a spreadsheet as well. I'm developing a list of the good plans and the bad plans, so I can use the good plans and the high payments as leverage in my appeals for all of my clients.

Host: Yeah, because you want to know not just what the good plans are to get those but what the bad plans are to avoid those, absolutely. So now, the claims have processed, right? And they didn't process correctly. They paid super low, and now we need to go on to plan B, which is filing an appeal. How does a provider or anybody in healthcare prepare an effective appeal, in your opinion?

Thomas J. Force: If you're out-of-network, there are some forms you need to shorten the revenue cycle that you're not going to need for in-network. For example, it's imperative to have an effective assignment of benefit, not just assigning the rights to the provider but also if you have a billing company like my company, the Patriot Group, you want to sign and designate Patriot Group as an authorized representative of the provider and the patient. There are some carrier-specific forms like DOR forms, designation of appointment of authorized representative forms that the carriers require. We need to get those forms. We don't want to delay an appeal. Once an appeal is sent, we're going to check all the boxes. If you're an out-of-network surgeon doing procedures at an in-network facility, you need to be aware of the No Surprises Act Bill. The patient needs to waive. That is a form to waive the protections under the act so you can bill the patient cost share and not an in-network cost share. There's an out-of-network disclosure and financial agreement that's really, really important.

By the way, Meridith, I didn't mention this. I know I mentioned audits. A big issue right now that I'm seeing is Fee Forgiveness Audits. So, if you're an out-of-network provider, the insurance companies are auditing you, asking you if you're billing all of your patients for their cost share, deductibles, coinsurance, even sometimes the balance bill, charge minus payment. You need to be least attempting to collect that. You need to have copies of statements, because if you get an audit like that, for example, Cigna, I have a client, they're looking for all of their money back over the last several years, millions of dollars from a client because they never sent cost share letters. So, that's a big issue with out-of-networks right now. Make sure you're making an attempt to collect cost share. You're not routinely waving deductibles and co-insurance. That's a huge problem.

So anyhow, when I send an appeal to answer your question, I check all the boxes. I include, as Exhibit A, all the forms, like assignment of benefit, DOR forms. I let the insurer know that the No Surprise Act has been waived. I provide an out-of-network disclosure that the patient has been disclosed that the practice is out-of-network. That's my Exhibit A. Exhibit B is generally the EOB. And then, I make my argument. Is it a low-payment appeal? "Hey, this is a UCR plan you're allowing at a Medicare rate. That's unacceptable. We need five times Medicare." Or I have an EOB for another patient for the same plan, where you allowed 7% of charges. What's the difference here? If it's a medical necessity or an inclusive denial, you appeal that. But you have your forms as Exhibit A, your EOB as Exhibit B. You make the appeal. Keep your appeal to two pages. The carriers have short attention spans, and they don't have the brightest people in their Claim Departments or Appeals Departments. So, keep your appeals short, follow up aggressively. How many times I've been told that the appeal was not received when I sent it certified and I have proof. Send your appeals by fax, certified. Send them by certified mail. Have proof that they receive it, and don't accept the nonsense. Those appeals need to be responded to in 60 days.

Host: Very excellent. So, you had mentioned briefly about employer appeals. What are they, and how could the out-of-network provider file one of those?

Thomas J. Force: One of the benefits of requesting an SPD is that when I request it from the employer, I get a response from the employer's employee benefit department. I get contact information and an email address. Very, very important. So, when I exhaust remedies on an appeal on a case that I think is a slam dunk, I'm going to email the employer and say, "Hey, remember me I'm the guy that asked you for the plan document. Thank you so much for providing it. I know that your administrator, Aetna, has a lot of discretion under the plan. But this plan allows 300% of Medicare and they're allowing it at 50% of the Medicare rate. Please intervene." And they do. So, that's an employer appeal, and they're sometimes very effective. Another benefit of requesting an SPD, Meredith.

Host: That's a powerful tool to have in your back pocket against these carriers that aren't processing claims correctly according to the SPD. Well, Tom, I mean, you've provided our audience with very valuable information today. Do you have any parting advice for the out-of-network provider?

Thomas J. Force: Yeah. I think it's very profitable to be out-of-network. I just think you have to make sure that your practice or your billing company understands the compliance risks and hurdles and make sure that they're prepared for those. Because the carriers will put a lot of obstacles in front of you. They're easily overcome, but you need to identify them so that you can overcome them.

And I think that you need to be more aggressive in the follow up for sure. And hopefully, those listening to this podcast will have some good tips in order to have their revenue cycle people execute a very effective workflow for out-of-network. And again, get two highly paid UCR plans allowed at 50%, 60%, 70% of charges out of 10. And you'll make significant amount of money. And I want to thank you for your time today, Meredith. Thanks for inviting me.

Host: Oh, thank you so much for taking the time to explain the out-of-network revenue and how these out-of-network providers can really maximize their revenue. So, it was a pleasure speaking with you today. Thanks, Tom.

Thomas J. Force: Likewise, Meredith. Take care. Have a nice day.