When providers render “out-of-network” care, reimbursement is generally limited to the usual and customary rate (UCR). Problems arise based upon how this term is defined and calculated. A payer is bound to its definition of UCR in applicable provisions of its policy or plan document. However, payers routinely use varying methods of calculating payable amounts in order to cost contain, instead of keeping with policy requirements.
Providers routinely accept these low UCR determinations rather than disputing denials or calculations because payers’ appeals processes are time consuming and difficult to navigate. Further, they can generally balance bill the patient, and while there are typically no legal impediments to balance billing patients, there are often financial limitations on a patients’ ability to pay.
Recently, payers have increasingly turned to “expert” repricers and cost containment companies to manipulate lower UCR rates using concealed and invalid “data”. Incredibly, these “experts” often receive more money for determining this low UCR than providers receive for rendering the treatment.
Many times, there are conflicts between UCR definitions in Summary Plan Descriptions (SPDs) and the actual underlying Plan documents issued by self-funded employer groups to their employees. When those conflicts occur, the underlying Plan documents rule, but getting to those documents is very difficult and time-consuming, making the appeals process laborious and costly.
- TGF has the legal expertise to combat improper UCR determinations and obtain additional reimbursement for providers at reasonable rates
- Payers and repricers must follow the terms of the Plan document or patient policy — and those terms rarely allow for exceptionally low UCR determinations
- TGF expertly advocates for providers’ rights in this area whether the issue is governed by ERISA, state, or other law