Cohen Howard’s Managing Partner, Leslie Howard, states that after representing the out-of-network provider community for over a decade, forming CHRMS as a revenue cycle management company that provides services at any stage of the billing and claims management process – whether it be obtaining authorizations for GAP exceptions, billing medical claims, filing administrative appeals, handling federal or state independent dispute resolution (IDR) arbitrations or pursuing additional payments for aged under-reimbursed claims pre-NSA – was necessary to serve our clients and their patients.
“Out-of-network providers operating in the healthcare insurance industry today need business and legal advisors with an entrepreneurial mindset. Cohen Howard’s model of driving additional value through CHRMS provides our clients with a comprehensive solution, with access to high-quality legal and business teams under one umbrella, who understand the entire claims process–from beginning to end. Our model promotes the flexibility and creativity needed to react to this ever-changing, chaotic landscape of health insurance,” Howard commented.
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Out-of-network providers operating in the healthcare insurance industry today need business and legal advisors with an entrepreneurial mindset
The NSA has markedly changed the reimbursement landscape, particularly for out-of-network providers, as billing patients more than their in-network cost-sharing obligations is no longer permitted.
With time-sensitive regulations and a more complex process for handling claims, providers are challenged to find highly skilled, qualified specialists who can effectively analyze claims, identify the appropriate course of action, and navigate the deadlines, requirements, and processes to successfully manage their claims. Amy Wilkins, Chief Operating Officer of CHRMS, added, “creating a specific department that handles only claims falling under the federal NSA or state specified surprise billing laws to our suite of revenue cycle management services was a critical step in supporting our clients’ needs.”
The NSA applies to virtually all group and individual health plans, including ERISA, non-ERISA, fully insured, and self-insured plans, for all emergency services and elective services. There is a major misconception in the provider community that the federal surprise billing law applies only to emergency surgeries. “This is definitely not the case,” David Boden, President of CHRMS stated. “The NSA can apply to elective surgeries as well under many circumstances.”
“We are seeing out-of-network providers failing to realize that many of their claims are now subject to surprise billing laws and continue to ignore the remark codes on EOBs that indicate the claim falls under the NSA or a state-specified law. By the time a provider realizes that the claim falls under the surprise bill regulations, it is too late to initiate independent dispute resolution, and the provider is left with no recourse for challenging the low reimbursement,” Boden says.
Out-of-network providers finally have the opportunity for a full and fair review of their claims by a neutral party who will determine what is fair payment based on many factors, removing their patient from the dispute and the control that the insurance payors have had over the out-of-network provider community for years. “Over the years we have seen most out-of-network fee schedules in health insurance plans become increasingly diluted, sometimes paying less than or at Medicare rates. Under the surprise billing regulations, the plan fee schedule no longer matters to a provider’s reimbursement outcome,” Wilkins commented.
“Our clients are finally getting recognized for the highly complex, at times lifesaving, procedures they perform that require years of training,” Wilkins says. “Through our efforts, our clients are seeing favorable outcomes. We believe in the long run this will strengthen the care for patients needing complex surgeries as fair and reasonable payments will allow for these talented surgeons to continue in business.”
With an exclusive focus on out-of-network surgeons, CHRMS stands as a unique and unrivaled company dedicated to securing fair and reasonable compensation for services rendered by these specialists. At CHRMS, surgeons gain access to unparalleled expertise, extensive experience, and a wealth of resources that will effectively navigate the intricate regulations and overcome the challenges presented by the NSA.
