How to Negotiate for Full Payment of Your Medical Billing - dummies

How to Negotiate for Full Payment of Your Medical Billing

In medical billing, there are two scenarios once the claim has been processed, receiving payment or negotiation. If the provider and payer have a valid contract on the date the service was rendered, the payment that the payer issues should be correct. If the payer and provider don’t have a contract, the payer may send the claim to be priced by a third party in a process known as negotiation.

Some payers use third-party pricing companies to negotiate pricing for out-of-network claims. These companies serve as intermediaries in the negotiations between payer and provider. The intermediary contacts the provider and offers a negotiated settlement amount that is specific to an individual claim. Normally, this settlement offer also includes a prompt payment clause. After the provider signs the settlement, the payer sends the agreed upon payment.

In a negotiation, the intermediary may do the following:

  • Arbitrarily price a claim and state that the pricing is “usual and customary” based on the geographical area where the services were provided: These claims are often underpriced, so be prepared to challenge the pricing.

  • Submit a settlement request to the provider: These settlement agreements normally obligate a discounted payment to be sent within a specified time, usually 10 days or less.

These negotiation attempts are just that — attempts. The provider isn’t obligated to accept the offer. In fact, providers should counter any initial offer they receive from a payer in these circumstances:

  • When a contract exists between provider and payer: If the claim doesn’t pay as specified by the contract, you should immediately notify the payer of the issue. Often, you can simply send the claim back with a notation explaining how the claim should have processed.

  • When no contract exists between payer and provider: In this situation, the payer isn’t entitled to a discount, even though the payer looks for a discount in most cases.

    If the provider hasn’t accepted a pre-payment price reduction but the payer takes one, immediately notify the payer in writing that the payment is not acceptable. This written notice, sent upon receipt of an under-paid claim settlement, is known as a claim appeal. The important part of the appeal is to know the payment rules and stand firm on them.