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Hi shashank!
Great questions.
First, on the Humana claim, when you performed the benefit verification for this patient's policy, was there both in and out of network benefits available (PPO policy), or was there only in-network benefits available (HMO policy)?
Also, what service(s) was the claim for? Sleep apnea, TMD, oral surgery, or something else?
Second, on the expedited agreement from multiplan for United Health - did the negotiator you spoke with agree to the 5% lower figure you offered? If they did accept it, your reimbursement check is likely currently being processed. If they did not accept it, the claim will process through as a normal claim would, but is likely still processing. Have you followed on to check on the claim status yet? (that would be your next step).
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I was going through your blog. It is very interesting. I have question. I just started working as a medical biller. 2 weeks ago I sent out my first ever 2 claims from our providers office. 1st to Humana and 2nd to the UnitedHealth. We are out of network with both of this insurance company.
1st claim(Humana)-
I got claim status that they are not paying us. member responsible for all the charges. because charges exceeds maximum allowable fee scheduled.
I need to know what is the next step to get reimbursed from insurance company.
2nd claim (United Health)
we have received fax from Multiplan with negotiated amount. which is underpayment of the services we originally claimed for. this negotiator called me. after some talking she raised only couple hundred dollars. I refused to negotiate with them at the negotiated price. I offered to take 5% off from original billed amount. Still waiting for an answer from negotiator.
In this case what is the process or how to deal with them?
Since this my 1st month working as medical biller. i need some guidance in this matter.
Thanking you
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Thank you for sharing your experience Guest! It's so very important to share with each other to keep a good pulse on new trends in medical billing in dentistry.
Anyone else who has an experience, good, bad or neutral with expedited agreements: please feel free to share!
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I was reading old messages and thought I would share a recent issue I had with MulitPlan and why I no longer every agree to their requests. I had obtained an out of network exception for a pt with a high out of network deductible that did not cross apply, he had met the in network deductible already. We were all set to go for in network coverage. I decided to agree to the Multiplan terms, when I received the claim it was processed out of network, so i resubmitted to be corrected using the in network approval we had received. The refuse to pay using the in network exception now,I have sent it back twice and they are saying that the agreement with Mulitplan overrides the in network exception that we had gotten! By phone the customer service reps are saying it does not override but they really dont know,the claims processing wont reprocess the claim in network now leaving no coverage for the pt. So frustrating!
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Hi bguthrie!
Yes you will see those expedited agreements every so often from companies like multiplan! Those are in response to a claim filed, this won't have anything to do you with your gap or pre-auth request :)
You are NOT required to accept the expedited amount. This is completely up to you.
The up side of accepting is that you will receive the listed reimbursement amount quicker - however, keep an eye out for language on that agreement that states you will also automatically accept that amount for that service for any other insurer who is contracted with multi plan that you may file a claim with in the future!!!!
The only down side is that if you do not accept, it will take additional time to receive the reimbursement (however, the reimbursement amount you receive will be higher that what is listed on the agreement).
Many providers choose to simply fax the agreement back with big letters (written in a sharpie marker :)) that says "we do not negotiate our fees, please process claim" or you can call them and tell them that as well.
Sometimes, if you do not accept the first agreement, they will try again with a slightly higher amount - but it is still an expedited agreement!
Hope this helps! Let us know if you have any further questions.
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Being very new to medical billing, these forums have been very helpful!
I am still working through my first claim. Pre-auth for sleep appliance, request for gap exception, and the claim for the initial exam was sent out about 10 days ago.
Today in the mail I received an "Expedited Agreement". Not sure if this was in response to my gap exception request or would have been sent anyway in response to my exam claim.
It is from a 3rd party (Multiplan) on behalf of Cigna Healthcare.
It states "Cigna has contracted with Multiplan to facilitate resolution of the above referenced services due to the provider being out of network for this claim. This agreement may expedite payment and decrease the patient's responsibility. Accept the Expedited amount listed below as payment in full (less deductible/copay) for services rendered."
In case anyone is curious, we billed $148 and they are offering $96.20 plus the patient copay portion of $25 ($35 for specialist but I assume we are more primary care?)
Have you seen these before?
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