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Copyright©2014CollectRxInc.Allrightsreserved.ThesematerialsincludeconfidentialandproprietaryinformationofCollect Rx,whichmaynotbeused,reproduced,stored,ortransmittedinanyformorbyanymeans– electronic,mechanical,photocopying,recorded,orotherwise– withouttheexpresspermissionofCollectRx.
5BigOut‐of‐NetworkMythsDebunked
CollectRxExpertise
CollectRx:TheOut‐of‐NetworkExperts
• Focus:helpingprovidersmaximizereimbursementsonout‐of‐networkbills
• Startedin2006
• Morethan800customersnationwide
• Customersincludeambulatorysurgerycenters,physiciangroups,hospitals,andlabs
• CreatedCRXIS™proprietaryOONdatabase
• Builtteamofexpertswhoformerlyworkedforinsurancecompaniesandtheirvendors
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TheCollectRxDifference
Devoted100%tohelping providersincreaseout‐of‐networkreimbursements
Focusedsolelyonout‐of‐networkbills
Handleover$1billionannually inout‐of‐networkbills
Comparabledatafrom1,200+customersnation‐wide
Understandthefinancialandcustomerincentivesofpayors andtheirvendors
Stableofattorneysthat assistasnecessaryatnoextracharge
Keys
Time&Persistence
Focus
SpecializedOut‐of‐NetworkExpertise
Comparable Data
KnowledgeofPayor‐SideIncentives
HealthcareReimbursementAttorneys
HowtoIncreaseOut‐of‐NetworkReimbursements
PayorTacticstoDecreaseYourRevenue
InsuranceCompanyTactics
HowpayersreduceOONpayments
1. Billreductiontactics
2. Limitedbenefitpolicies
3. ThirdPartyRentalNetworkContracts&ContinuousDiscountAgreements
InsuranceCompanyTactics
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BillReductionTactics
Negotiation
Faxedsettlementproposals
Shortturnaroundtime
CollectRxNegotiation(Pre‐Payment)Service
InsuranceCompanyTactics
BillReductionTactics
Re‐pricing
Insurancecompanysendssignificantlyreducedpayments
CollectRx(Post‐Payment)AppealService
InsuranceCompanyTactics
Over800companiesarehelpingpayorsreduceout‐of‐networkpaymentstoproviders.
*“MaximizingSavingsfromNon‐NetworkExposure”,KarlHuff,AHIPCoverage,July/Aug2005.
$5billion peryearinreducedproviderrevenuesforout‐of‐networkbills.*
InsuranceCompanyTactics
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LimitedBenefitPolicies
Limitedbenefitpoliciestoreduceallowable/R&CAmounts
UtilizeMedicare‐basedpricing(ex:UnitedHealthcareMNRPandCignaMRCpolicies)
Askthepayerduringbenefitverification
InsuranceCompanyTactics
Out‐of‐NetworkReimbursements–CommonMyths
1. “Thedaysofout‐of‐networkareover.”
2. “Being100%in‐networkmaximizesreimbursements.”
3. “Ihaveathirdpartyrentalagreementthatcoversit.”
4. “We’redoingfine.”
5. “Outsourcingdoesn’tmakesense.”
CommonMyths
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1. “Thedaysofout‐of‐networkareover.”
Myth1:DaysofOONareOver
Myth1:DaysofOONareOver
Annually$60BinOONclaims
ContinuedgrowthinPPOenrollment
Increaseinnarrownetworks
PeoplewantinsurancepolicieswithOONbenefits
Myth1:DaysofOONareOver
Annually$60BinOONclaims
ContinuedgrowthinPPOenrollment
Increaseinnarrownetworks
PeoplewantinsurancepolicieswithOONbenefits
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Myth1:DaysofOONareOver
Annually$60BinOONclaims
ContinuedgrowthinPPOenrollment
Increaseinnarrownetworks
PeoplewantinsurancepolicieswithOONbenefits
Aninsuranceplanlimitingthenumberofparticipatingprovidersinexchangeforareduced
premium.
Myth1:DaysofOONareOver
Whatisanarrownetwork?
LessChoice=LowerPremiums
Myth1:DaysofOONareOver
Whynarrownetworks?
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Myth1:DaysofOONareOver
ImpactonOut‐of‐Network
Myth1:DaysofOONareOver
Annually$60BinOONclaims
ContinuedgrowthinPPOenrollment
Increaseinnarrownetworks
PeoplewantinsurancepolicieswithOONbenefits
1. “Thedaysofout‐of‐networkareover.”
2. “Being100%in‐networkmaximizesreimbursements.”
CommonMyths
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Myth2:Being100%In‐NetworkMaximizesReimbursements
Out‐of‐Network
ReimbursementsAre
AlmostDouble
In‐Networkreimbursements
DevelopingtheOptimalIn‐Network/
Out‐of‐NetworkStrategy–
AHybridApproach
Myth2:Being100%In‐NetworkMaximizesReimbursements
DevelopingYourOut‐of‐NetworkStrategy–
Localpayermix
Localemployermix
Comparablereimbursementlevelsformostcommonprocedures
Relativemarketshare
Myth2:Being100%In‐NetworkMaximizesReimbursements
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Comparein‐networktoout‐of‐networkreimbursementlevelsforcommonprocedures‐
Numberofcases
x
AverageReimbursementLevels=
TotalReimbursement
Myth2:Being100%In‐NetworkMaximizesReimbursements
DevelopingYourOut‐of‐NetworkStrategy–
“DipYourToeintheWater”
Myth2:Being100%In‐NetworkMaximizesReimbursements
$127,966peryearinadditionalout‐of‐networkpayments
TypicalSurgeryCenterUsingCollectRx
Myth2:Being100%In‐NetworkMaximizesReimbursements
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1. “Thedaysofout‐of‐networkareover.”
2. “Being100%in‐networkmaximizesreimbursements.”
3. “Mythirdpartyrentalagreementcoversit.”
CommonMyths
Whatisathirdpartyrentalnetwork/silentPPO?
Aninsurancecompanytactictolowerreimbursementsbyaccessingthediscountedratesofanotherinsurer,typicallywithouttheprovider’s
knowledge.
Myth#3:MyThirdPartyRentalAgreementCoversIt
Whoisthecustomer?
Patient– NOProvider– NO
InsuranceCompany– YES
Myth#3:MyThirdPartyRentalAgreementCoversIt
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Doesthecontractprovideforpatientsteerage?
KeyIssuestoConsider
Myth#3:MyThirdPartyRentalAgreementCoversIt
Areprovidersawarethattheyhaveenteredintotheseagreements?
KeyIssuestoConsider
Myth#3:MyThirdPartyRentalAgreementCoversIt
Isthepayerrequiredtousethecontract?
KeyIssuestoConsider
Myth#3:MyThirdPartyRentalAgreementCoversIt
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Areratesadequateascomparedtoout‐of‐network?
KeyIssuestoConsider
Myth#3:MyThirdPartyRentalAgreementCoversIt
KeyIssuestoConsider–Allowedvs.BilledCharges
BilledCharges $10,000
AllowedCharges‐% 60%
AllowedCharges‐ $ $6,000
DiscountedRatePerAgreement 70%
Reimbursement $4,200
Myth#3:MyThirdPartyRentalAgreementCoversIt
Contractstartdate:July1,2017
Providerseekstoterminate:April1,2018
Fewerthan180daysbeforeanniversaryofJuly1,2018
Terminationbecomeseffective:July1,2019
KeyIssuestoConsider–Termination
Myth#3:MyThirdPartyRentalAgreementCoversIt
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Arepayersabletoapplyin‐networkdiscountsbutusehigherout‐of‐networkdeductiblesandco‐pays?
KeyIssuestoConsider
Myth#3:MyThirdPartyRentalAgreementCoversIt
Doesitincorporateadministrativehandbooks?
KeyIssuestoConsider
Myth#3:MyThirdPartyRentalAgreementCoversIt
TheBottomLine
KeyIssuestoConsider
Myth#3:MyThirdPartyRentalAgreementCoversIt
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1. “Thedaysofout‐of‐networkareover.”
2. “Being100%in‐networkmaximizesreimbursements.”
3. “Ihaveathirdpartyrentalagreementthatcoversit.”
4. “We’redoingfine.”
CommonMyths
Resourceallocation
Expertise
Lowvolume
Myth4:We’redoingfine
Resourceallocation
Dedicatedresources
Data
Appealprocess
Audit
Expertise
Lowvolume
Myth4:We’redoingfine
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Docs
PayorVerification
Strategy
PayorEngagement
Settlement&Follow‐up
AppealProcess
Myth4:We’redoingfine
AuditingOONActivity–CRXIS™ RevenueRecoveryService
Identify accounts with potentially recoverable underpayments
Minimal staff effort
Recovered revenue flows to bottom-line
Myth4:We’redoingfine
Startsbyrunningareportofout‐of‐networkactivityforthepastyear.
CollectRxanalyzesthecases usingitsproprietaryCRXIS™businessintelligenceengineandexpertisetoidentifythebillstoappeal.
CollectRxusesitsproprietaryappealsprocessestoobtainadditionalpaymentsfromtheinsurancecompanies.
WhatistheCRXIS™auditprocess?
Myth4:We’redoingfine
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Myth4:We’redoingfine
NegotiationResults• Time – First 4 Months
• Prior to Collect Rx - Average Settlement 80.0% of billed charges
• With Collect Rx - Average Settlement 94.1% of billed charges
Billed Charges
CRX Settlements
Revenue Increase(net of fees)
$1,502,843 $1,414,435 $135,395
• Average Monthly Revenue Increase - $33,849
AppealResults
Myth4:We’redoingfine
Out-of-Network Payers: Aetna, Assurant, Cigna, UHC
Cases appealed: 73
Successful cases: 45
Billed Charges
Initial Payments
CRX Additional Payments
$1,662,768 $363,509 $314,434
Resourceallocation
Expertise
ReviewingEOBs
Assignmentofbenefits
Documentingallcalls
Recordingreferencenumbers
Lowvolume
Myth4:We’redoingfine
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EOBExamples:
“Paymentsofbenefitshasbeenmadeinaccordancewiththetermsofthemanagedcaresystem”
“Chargeexceedsfeeschedule/maximumallowableorcontracted/legislatedfeearrangement”
Expertise– TranslatinganEOB
Myth4:We’redoingfine
Expertise– AssignmentofBenefits
(1) Assigns the provider all rights under the insurance policy (including the right to appeal and the right to receive relevant documentation)
(2) Refers to the provider as the patient's authorized representative
(3) References ERISA and a full and fair review of claims
Myth4:We’redoingfine
Resourceallocation
Expertise
ReviewingEOBs
Assignmentofbenefits
Documentingallcalls
Recordingreferencenumbers
Lowvolume
Myth4:We’redoingfine
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Resourceallocation
Expertise
ReviewingEOBs
Assignmentofbenefits
Documentingallcalls
Recordingreferencenumbers
Lowvolume
Myth4:We’redoingfine
Resourceallocation
Expertise
ReviewingEOBs
Assignmentofbenefits
Documentingallcalls
Recordingreferencenumbers
LowVolume
Myth4:We’redoingfine
% of Revenue
fromOON Bills
$5Million
15%
NetRevenue
Increase in Allowable Amount
33%
AnnualIncrease in
Reimbursements
$247,500
50%
5% $82,500
$825,000
X X
X
X
=
=
=
Myth4:We’redoingfine
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1. “Thedaysofout‐of‐networkareover.”
2. “Being100%in‐networkmaximizesreimbursements.”
3. “We’vegotitcovered.”
4. “We’redoingfine.”
5. “Outsourcingdoesn’tmakesense.”
CommonMyths
DoIhavetheexpertise?
DoIhavetheresources?
DoIhavethedata?
Howdoestheoutsourcedvendorchargefortheirservices?Upfrontcosts?On‐goingminimums?
Attheendoftheday,doesitmakefinancialsense?
Outsourcing– QuestionstoAsk
Myth5:OutsourcingDoesn’tMakeSense
1. “Thedaysofout‐of‐networkareover.”
2. “Being100%in‐networkmaximizesreimbursements.”
3. “We’vegotitcovered.”
4. “We’redoingfine.”
5. “Outsourcingdoesn’tmakesense.”
CommonMyths
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