Revenue Recovery And Compliance Tips For The Out-Of-Network Provider

Revenue Recovery and Compliance are two of the most important business operations at a health care provider’s facility. Unfortunately, they can also take up a lot of your staff’s time and resources. We’ve compiled a list of helpful practices to help reduce costly mistakes, and improve efficiency.

Recovering Lost Revenue

Many healthcare providers are faced with the uphill battle of recovering payments for services they provided. These delayed or lost payments can add up quickly and become a drain on your staff.

Here are a few tips that can help you increase your health care facility’s bottom line:

‍Gather proof of submission and receipt of claim: All too often, insurers will deny or delay reimbursements to health care providers because of incomplete or missing claims. A call to the health insurer will be met with the infamous “No Claim on File”.

To hold insurers accountable, ensure you have:

  • A copy of the claim
  • Proof of submission
  • A receipt of the claim

– If the claim is submitted electronically, your clearinghouse can give you access to a report verifying that claims were received by the health plan. Simply send this proof to the health plan representative who tells you there is no claim on file.

– If claims or appeals are filed on paper, send them by certified mail, return receipt requested. You should at all times try to send claims electronically as these claims will be processed quicker and you will receive faster claim payments.

Identify accounts that are least likely to pay:

  • Should be quickly appealed
  • Ensure that your patients agree in writing to be responsible ultimately for the charge, uncovered services, pre-certification and referral requirements
  • Have patients sign an Enforceable Assignment of Benefits form

– AOB forms not only assign a claim benefit or payment to the practice, but assign other rights to the provider and their representative such as the right to file claims, appeal and even to litigate against the health plan.

– All appeals should include an enforceable AOB signed by the patient.

– If you would like a copy of an enforceable AOB form, email

‍Use ERISA to recover your rightfully owed reimbursements: Health Plans that are employer-sponsored are governed by ERISA, a federal law.

Under ERISA, health insurers have many responsibilities and obligations to ensure quick and accurate claim payments.

Out-Of-Network providers that have complete understanding of the law will help their billing staff recover claim revenue faster and at a higher reimbursement rate
ERISA exempts plans that cover municipal, government or state workers and religious entities

Use Government Regulatory Bodies to Get Claims Paid:

If you are dealing with an ERISA Plan, file your complaint with the United Stated Department of Labor, Health Bureau

NOTE: Preferred that complaints be filed by patient and not the provider or your counsel.

If you are dealing with an ERISA-Exempt Plan, or fully insured plan, file your complaint with your State’s Insurance Department

You may also file complaints with the State’s Attorney General.

‍Staying in Compliance

Keeping up with compliance changes in a digital world can be exhausting, but is a requirement to avoid costly mistakes.

Here are a few tips that you can use to ensure you meet compliance standards:

  • ‍Create a compliance checklist: A compliance checklist is your first step to make sure you are compliant with HIPAA, ERISA, and other legislations.
  • Consult an attorney: Hiring an expert, such as Thomas Force & The Patriot Group, in compliance and law can save your health care facility time stress, and money.
  • Fight back against health plan recoupments, refund demands, or SIU investigations.
  • Determine the exact reason why the insurer believes they are entitled to recoupments
  • Ensure you make an ERISA Demand, requesting the insurer’s entire investigative file
  • Hire an attorney with experience in out-of-network investigations and health plan recoupment defense‍

How The Patriot Group Can Help

The Patriot Group and their Law Firm, The Force Law Firm, PC., are managed by highly trained attorneys with experience in the area of Appeals, Revenue Recovery Techniques and Recoupment Defense. They provide the highest quality of revenue recovery and compliance services for healthcare community by advocating and fighting for the rights of its healthcare physician facility clients and their patients with the various insurance companies.

Scroll to Top