Successfully Navigating Balance Bill Negotiation Challenges

A referral for a VIP member was received by Phia’s balance bill intake team, totaling an amount of over $68k. After the initial allowable, the outstanding balance remaining was north of $38k. With VIP members, all parties are heavily involved and sensitive to a quick and efficient resolution.

 

Phia attempted to negotiate the claim based on a benchmark of 175% of the CMS estimate, which was denied by the provider. Rather than providing a counteroffer, the provider advised Phia that they would not negotiate and that the full billed amount was expected. Despite this rigid stance, the client requested that the claim be reapproached with an offer of 50% of billed charges. A supervisor at the provider’s office advised that while 50% of billed charges would not be accepted, a potential alternative would be for the Plan to pay 50% of the remaining balance, which equated to approximately 248% of CMS. The Plan and Phia agreed to move forward with that proposal.

 

An agreement letter was presented to the provider, and multiple outreach attempts were made, but the contact who suggested this agreement ultimately rejected the offer without providing a rationale. Phia raised these concerns to a manager at the provider and began thinking of alternative methods for settlement. The plan had agreed to make an additional payment of 275% of Medicare as a good-faith effort to resolve the balance at hand, but there was no agreement in place. This payment was received by the provider, and in turn, a director gave the Phia claims handler a call to discuss the account. The director at this provider acknowledged the miscommunication, apologized for the delays, and confirmed that the payment was not only received but would be accepted as payment in full. In order to memorialize this agreement, Phia sent over a release that the director promptly signed and returned for Phia and the plan’s records.

 

By partnering with The Phia Group, the Plan saved over $15,000.00 and had a pleased VIP member who was no longer going to be receiving collection notices and calls on this balance.