IDRs FOR ENHANCED EMERGENCY ROOM REIMBURSEMENTS

By Laura J. Lowenstein, Esq.                                      

In New York, effective March 31, 2015, Insurance Law Section 3241(c) and Financial Services Law Article 6 created a new paradigm for consumer protection against out-of-network emergency services bills.  On a very macro level, the law is meant to remove the patient from theER SCRUB equation and aims to hold them harmless beyond what their patient cost-sharing would have been had they been treated by a provider contracted with their health plan.  The physician and the health plan are left to “fight amongst themselves” regarding reimbursement and are provided with an arbitration forum – titled an independent dispute resolution (IDR) – whereby decisions are rendered when the two sides are unable to mutually agree as to a “fair” rate.

While seemingly straight-forward, the mechanics of the law can confuse even the most-savvy medical practices.  As a result, practices find themselves losing approximately $400 – on top of the claim’s already lost revenue – for every IDR they file and lose.  The problem?  Practices simply do not understand the whole system, including the governing regulations and how that translates into real everyday practice management.  There are a multitude of factors with every claim that determine not only the legally available tools for reimbursement but also the proper ones to use in the arsenal available for a specific claim.  The old-fashioned rote manner of billing, balance billing and collecting in the out-of-network world are not just unavailable but also noncompliant in the new Article 6 world.

The upside?  CRM recently analyzed the receivables (pre- and post- March 31, 2015) for some of our out-of-network provider clients and found that when billing and collections is done right, the practice’s receivables did shift as to source but not as to bottom line.  In fact, total receivables increased for some specialties proving that even within the IDR paradigm there is a way to avoid the linear relationship between increasing regulation and declining revenue.

 

If you are an out-of-network provider who takes Emergency Room call, contact us today at 1-844-277-3277 to learn how Capital Resource Management, Inc. can provide compliant, effective and exhaustive billing and collections services to ensure maximum reimbursement on every claim. 

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