Out-of-Network Claim Negotiation

• Why do you need to negotiate fees if we already have a PPO provider?

  Although there are thousands of PPOs in the United States, there are none that have every provider under a contractual relationship. Patients may seek treatment from one of these providers and, without negotiation, their payment will be based upon the provider’s billed charges.

• How do we get providers to negotiate fees?

  Although each situation is unique, nearly all providers have some contractual relationships in place and understand that discounting of their fees is expected. If an insured seeks treatment from a non-contracted provider, these providers will often negotiate rates for any number of reasons. These may include:

  • lessening of payment burden on the insured if coinsurance is applicable
  • prompt payment guarantees
  • retaining patient if treatment is to be ongoing
  • prospect that usual and customary (U&C) may be applied

• What types of discounts can be expected?

  Because each situation is unique, answers to this question can vary widely. Discounts can range from as little as 5% to as much as 75% for some high-cost infusion therapies.