Listen to the complete discussion
This conversation focuses especially on anesthesia and other out-of-network provider groups navigating the No Surprises Act. Use the chapter guide to jump directly to a topic.
Out-of-Network Reimbursement Q&A
Jeffrey Halkovich on eligibility, QPA payments, open negotiation, IDR documentation, and protecting claims from administrative loss.
Chapter guide
Claims can be lost before arbitration
Jeffrey's central operational point is that a viable dispute can disappear before its merits are considered if the claim is not identified and acted upon in time.
Read the selected transcript
Jeffrey Halkovich: So really what it comes down to now is that, yes, the strategy has changed, but it's very important what group a provider works with, because most of the loss happens on the administrative side, on failing to identify claims, whether at all or in a timely manner.
Why the initial QPA offer may persist
In discussing his practice experience, Jeffrey describes open negotiation as a required stage that often does not produce a materially different payer offer. That observation is not a universal statistic for every payer or claim.
Read the selected transcript
Jeffrey Halkovich: What you'll see a lot is, yes, that initial QPA payment is usually the offer that you see persist through the whole process. It's not as though, you know, you'll send in a bill on an original claim, you'll get a low payment for the QPA because the No Surprises Act applies. Because you're required to engage in the open negotiation process, you do. But what you 99% of the time find is that there's no meaningful offers that are made. There's no meaningful negotiation. And there's very rarely an offer that gets to the point where, you know, you would be willing to accept to settle that claim.
Documentation can sharpen the IDR presentation
The discussion identifies provider credentials, training, facility context, case mix, teaching status, and procedure acuity as information that may help organize a claim-specific submission.
Read the selected transcript
Jeffrey Halkovich: Just getting, you know, really good CVs from the doctors, understanding their training and their history, understanding the facilities where they're doing these cases, what type of cases traditionally get done there. Are they teaching hospitals? Are they not? Looking at the acuity of the procedures and kind of documenting all this stuff. Yeah, that's where I think you can make an impact more so.
The most expensive administrative mistake
For higher-volume provider groups, Jeffrey emphasizes that many comparatively smaller claims can add up to meaningful revenue. Identification, staffing, and timely action therefore matter at the portfolio level.
Read the selected transcript
Jeffrey Halkovich: And we've touched on it, and it's the same theory. It's working with a group that, one, doesn't know what they're doing, doesn't have the staff to identify the claims, doesn't move on the claims in a timely manner because of the volume of claims that anesthesia generates. They're generally more volume, lower dollar than lower volume, higher dollar claims.
What I see that they're making is administratively losing those claims to IDR by not having the proper people or the proper staff identifying and taking action on it. Once you're in a situation where legally and factually it applies, like we spoke about, if you take no action on it, there's no more money coming. You can't go after the patient anymore. So you're just watching the claims die.
The billing company and the RCM company and the IDR company that you work with—it's critical that things don't get lost. I see so many times things getting lost that can turn into real revenue. Small-dollar claims, people don't—but they add up. And when they add up en masse, they create a problem.