Out-of-Network Negotiation Services

Pre-payment negotiation happens when a repricing vendor contacts you with a discounted rate offer before the claim is paid. We evaluate whether the offer is reasonable or whether you should reject it and negotiate directly.

Post-payment negotiation applies when a claim has already been paid at an unacceptable rate. We reopen the case and pursue the balance owed. Many providers assume a paid claim is a closed claim. It isn't. You have appeal and dispute rights.

The No Surprises Act (NSA), effective January 2022, fundamentally changed OON billing for emergency services and certain non-emergency services at in-network facilities. Understanding these rules is critical for any facility that provides OON care.

Emergency services. Providers cannot balance bill patients for emergency services regardless of network status. The payer must pay a "reasonable amount," and if you disagree with the payment, your recourse is the independent dispute resolution (IDR) process — not the patient's wallet.

Non-emergency services at in-network facilities. If an OON provider (such as an anesthesiologist, radiologist, or pathologist) renders services at an in-network facility, the patient cannot be balance billed unless they received proper advance notice and gave written consent at least 72 hours before the service.

Air ambulance. OON air ambulance providers cannot balance bill patients. Ground ambulance is currently exempt from the NSA, but CMS has an advisory committee studying potential future regulations.

IDR process. When payer and provider can't agree on payment, either party can initiate independent dispute resolution. An IDR entity (arbitrator) selects the "most reasonable" offer — the payer's or the provider's. There's no splitting the difference. This makes it critical to submit a well-supported offer with FAIR Health data, Medicare benchmarks, and documentation of the complexity of care provided.

Go Medical Billing has extensive experience with NSA IDR submissions and maintains a strong win rate by building data-driven cases that arbitrators find compelling.

Third-party repricing vendors are companies that insurance payers hire to reduce OON claim payments. The largest — MultiPlan, First Health, PHCS, and Data iSight — process millions of OON claims per year. Understanding how they operate is essential to fighting underpayments.

How repricing works. When an OON claim reaches a payer, instead of processing it against usual and customary (UCR) rates, the payer routes it through a repricing vendor. The vendor applies its own fee schedule — typically a percentage of Medicare rates or a proprietary database — and the payer pays the repriced amount. The discount can range from 40% to 70% off your billed charges.

Consent issues. Some repricing vendors claim you agreed to their discounted rates through your participation in a PPO network that has a "silent" or secondary network arrangement. You may be in MultiPlan's network without knowing it because a PPO you joined years ago has a downstream agreement. We audit your network participations to identify and terminate these silent PPO arrangements.

Fighting repriced claims. When a claim is repriced below a fair rate, we reject the repriced payment and negotiate directly with the payer. Our negotiation package includes: billed charges, Medicare benchmark comparison, FAIR Health 80th percentile data for your geographic area, documentation of any unusual complexity or circumstances, and a demand for payment at a fair rate. Most payers will negotiate to avoid the cost and uncertainty of IDR.

For facilities with high OON volume, we also conduct network participation audits to identify every silent PPO arrangement and help you make informed decisions about which networks to maintain and which to exit. Our credentialing and contracting team can then enroll you in the networks that make financial sense.

Every OON claim is different, and results depend on the payer, the service type, the geographic area, and the initial underpayment amount. However, our negotiation program consistently delivers meaningful improvements over initial OON payments.

Emergency department claims. ED physician claims are among the most commonly underpaid OON claims. Payers routinely pay 100% to 150% of Medicare for emergency services, while fair market rates in many areas are 200% to 400% of Medicare. We typically recover an additional 40% to 80% above the initial payment through negotiation.

Surgical and anesthesia claims. High-dollar surgical and anesthesia claims are where repricing vendors cut deepest. A spine surgery billed at $45,000 might be repriced to $8,000. We build detailed cases showing the complexity of the procedure, the surgeon's qualifications, and regional market data to negotiate fair payment.

Timeline. OON negotiation is not a fast process. From initial dispute to resolution, cases typically take 60 to 180 days. IDR cases can take 30 to 60 days after initiation. We manage the entire timeline and keep you informed at every stage. Our contingency fee structure means you only pay when we recover additional money — there's no upfront cost or risk to your practice.