Many hospital-based physician groups are out of network with health plans. With the changing legislative rules both at the state and federal levels – we work with clients to fight against the declining out of network reimbursement. There are many factors that go into determining a reasonable payment for out of network services and components that lead to arbitration when payers / providers do not agree on those terms.
There are many stipulations and requirements to go to arbitration such as a history of good faith attempts to contract with the payers. We use analytics and market rate data to prepare “good faith offers”, a requirement to proceed to arbitration, as a formal process to attempt to negotiate an in-network rate.