Out-of-network negotiation explained: pre-payment and post-payment
Out-of-network billing is the trickiest part of the industry. Understanding how pricing vendors work is the first step to recovering more.
Negotiating out-of-network claims matters most for hospitals and free-standing emergency rooms, where out-of-network exposure is highest. Insurers often route these claims through pricing vendors that propose settlements below what the service is worth.
Know the vendors
Pricing vendors such as Multiplan, Zelis, Viant and GCS evaluate claims on behalf of payers. Knowing their terminology and their methodology is what makes negotiation possible.
Pre-payment negotiation
This is negotiating an offer received before the claim is reimbursed. Time matters here — the earlier an offer is disputed, the more leverage remains.
Post-payment re-negotiation
When the claim has already been reimbursed based on vendor pricing, it can still be re-opened and negotiated. Building a database of historical outcomes makes underpayments easier to spot.
Protect the patient too
Analyze historical data for your locality and negotiate from that analysis. Patients should not be left with outsized out-of-pocket costs caused by an underpaid claim.
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