How to Resolve Medical Billing Disputes with Non-Contracted Payers

By Karen Smiley from Medical Billing and Coding For Dummies

As a medical billing professional, you may sometimes find yourself dealing with a dispute involving a non-contracted payer. Non-contracted payers are those with whom the provider does not have a contract. Payment for these claims is what is known as out-of-network, and you need to carefully investigate them prior to any patient encounter because some plans don’t allow for out-of-network services.

Plans that don’t allow payment for out-of-network providers may process the claim to make the entire billed amount the patient’s responsibility, or they may pay the claim without applying a discount.

Often, if a provider doesn’t participate in a certain network, the payer negotiates through a third-party pricing agent and tries to obtain a discount from the provider. Other times, if a provider contacts an out-of-network payer prior to a patient encounter, the payer asks for a one-time agreement for payment.

In cases where the payer denies payment and the plan provisions stipulate that the patient is responsible for all charges, most providers try to work with the insurance company to get the claim paid. Therefore, before sending the patient a bill, try to talk to the patient’s insurer to find out whether the issue can be resolved.

You also want to let the patient know that her insurer has denied payment and see whether either she or her employer can assist in resolving the issue.

When you deal with non-contracted payers, you need to rely on correct claims processing guidelines (published by the Centers for Medicare & Medicaid Services [CMS]) and the pre-encounter verification. Commercial payers can always cry “NCCI edits” when processing an out-of-network claim. After that, they are bound by the provisions of the patient’s coverage plan.

Patients are responsible for ensuring that any medical provider they seek treatment from accepts their insurance. However, the provider has a moral obligation, whenever possible, to verify patients’ coverage prior to treating them.