EP 106: Maximizing OON Reimbursement on Self-funded Plans with Ali Beheshti

Speaker A: Foreign.

Speaker B: Executive Podcast with your host, um, Nick Jaworski.

Speaker A: We bring you the business of recovery because those struggling with addiction need you to be here tomorrow as well as today. Thank you for joining me here on the Recovery Executive Podcast. I'm um, your host, Nick Jaworski, CEO of Circle Social Inc. A strategic marketing firm for behavioral health and addiction treatment providers. Today we're speaking with Ali Beheshti. He is the CEO of Zeely Innovative Payer Reimbursement company I guess would be probably the easiest way to explain it. So we're going to do a deep dive into some pretty complex areas of payer reimbursement outside of the normal particularly uh, around out of network. But we'll do some discussions around in network and contracting negotiations as well. Before we dive into that, I want to hear from our wonderful sponsors. Outcome Tracking is made easy with ERP Health ERP Health is the US Standard outcome tracking platform to deliver measurement based care for behavioral health. Their products are equipped with tools to improve population health, enhance the experience and outcomes of patients, and reduce the cost of care in our communities. Tracking outcomes to individualize treatment and deliver measurement based care benefits both providers and patients. You can visit erphealth.com to learn more and book a demo today. So as I mentioned, today we're speaking around payer reimbursement with a lot of emphasis on out of network claims for third party administrators for self funded plans. And so if you aren't familiar with some of that terminology or how that fits into the reimbursement landscape, don't worry, we are going to go over it in depth and provide the definitions and really explain uh, the complicated maze and web that is payer reimbursement. Particularly in the out of network space. When you're looking at full funded vs self funded vs third parties vs downline 3rd party payer reimbursements it gets pretty complicated. But that is exactly why I wanted to have Ali on because cause he knows this stuff from top to bottom and I found it incredibly helpful. So very excited to get into it with him and help everyone listening today better understand what's happening in the reimbursement landscape and find significant opportunity for potentially getting higher reimbursements and being able to provide the quality of care that you need for your patients with some of these self funded plans through third party administrators. So with that let's jump in. Thanks for taking the time to come on the show Ali. I really appreciate it. Can you tell us a little bit about yourself and your company?

Speaker B: Uh, sure. Yeah, thank you for having me. I really appreciate you inviting me. My name is Ali Beheshti, I'm the CEO of Zeeli and Zeely is a revenue cycle management company, uh, that specializes in substance use disorder and behavioral health disorder, uh, primarily for treatment centers, uh, in those sectors. Yeah. And uh, again it's a place pleasure to be on here and thank you for inviting me.

Speaker A: Well, appreciate you coming on. So payer relations and payer systems and processes and getting paid are obviously always very, very complicated. So whenever we have someone with a background, uh, in payer relations and reimbursement, I like to start at a high level and have you walk us through it a little bit. So payers have a lot of third parties do reviews and manage claims, negotiate rates and you guys are kind of inserted into that process. Is that accurate? I mean, can you walk us through a little bit of what that maze looks like and how you guys connect to it?

Speaker B: Sure, yeah. Well that's a good question. Um, and I won't get too much into detail at this point, but ah, as the questions progress, I will. But yeah. So the way it works, just like any healthcare provider in our sector, you submit claims and one would hope you get paid, but it's not that easy. It's far more complex like you said. And uh, in this space you always want to make sure you have a really uh, in depth verification of benefits process to make sure, you know, the payer covers the services you provide, whether you're in network or out of network with that payer and get, you know, so you can know the patient responsibility, whether it's deductible, coinsurance and so forth. So verification of benefits. And then also something that's unique about uh, this space is the utilization reviews are, it's not just one authorization. At the beginning of care, you're frequently doing what are referred to as concurrent reviews and getting additional care and constantly communicating with the payers. And then uh, finally you're you know, submitting claims and managing that. And, and it is a, like you said, a complex maze. Right. And uh, what I like to tell people is really understanding, which we'll get into more detail later, is the difference between who prices a claim for an in network provider, who prices the claim for an out of network provider. And then something very important that I think people overlook is how does a claim get priced when it is a, uh, self funded. That is uh, the most common is employer funded policies where the actual payer is not the insurance company themselves, but the employer group. Right. And the payer like a United or an AT is the administrator. So they refer to those, the payers refer to them, uh, those employers as ASO clients, uh, administrative services only clients. Right. And so that's a whole lot different than what are referred to as commercially funded or fully funded policies where the payer, the money being paid is being paid by the Uniteds, the aetnas, the cignas, the Anthem crosses. So who's paying you, right. Is very important especially to out of network providers. And navigating that who's paying you? Uh, and uh, is very important because how they pay you primarily depends on if you're out of network, who's paying you. And we can discuss that further.

Speaker A: So you mentioned that the payment of claims which is an important part of where you guys focus and just to kind of help everyone understand and get a framework to the conversation. You have a strong payer background obviously, but that's, you guys aren't like a billing company, you're not revenue cycle management. You actually have a specific area that Zeely focuses on currently. Do you just want to give us a little bit of background on what that is?

Speaker B: Sure, sure. Zeely did start out just so you know, as a full services billing company and we do still have clients for that. But our primary focus, what you're referring to is our boost platform. And the reason we focus on this is because of that complexity that you mentioned regarding out of, it's really out of network claims. So I always like to tell people, you know, there's kind of, there's two types of policies out there, uh, when you're an out of network provider, right. So you know, obviously there's PPOs and HMOs. You can't take HMOs, right? PPOs you can. But even PPOs, right, you have to understand the way they work is so differently. And I like to uh, again it all comes down to who's paying you. So it's fully funded, right? Uh, or commercially funded when the insurance companies paying you or it's self funded and the self funded policies. The reason it's so important to understand these self funded ones, and that's our primary focus is the US primary focus is post payment negotiations on self funded health insurance policies. Because a lot of these self funded health insurance policies have provisions in their underlying benefits, right. That allow you as the provider to go back to the, the payer. And in this case remember the payer is not the insurance company, it's the employer and the employer employs typically a third party Administrator. The most common third party administrator is a company called Multi Plan. Um, but they, they own a ton of subsidiaries that Eyesight Viant, so on and so forth and, and you know, there's plenty not owned by uh, Multi, uh, Plan as well, Navigard, you know, huh. Global Claim Service, so on and so forth. So there's a lot of these third party administrators of these patient protection provisions against balance billing. Right. And that's what it's all about. So what you do is you negotiate with them and you request additional funds. Okay. From them and they pay those additional funds. But in exchange the provider promises, I will not balance bill this client. And I think a lot of people, they don't exactly understand what is balance billing. So I think maybe I'll take a step back and explain that. You think that'd be helpful?

Speaker A: Yeah, yeah, definitely. I think, uh, for listeners, this is a lot of new information. So it'd be good.

Speaker B: Yeah, yeah. So balance billing. So let's say you have a PPO health insurance policy and you have a $500 uh, in network deductible and $1,000 in network out of pocket max. Okay? So you hear the term out of pocket max. You go to a network provider, you say the max I'm going to pay out of pocket is $1,000. And then of course I have my, my co pays, so you have that in addition and you a uh, ppo, you'll have the same, let's say the same exact policy, it'll have $1,000 out of network deductible and a $5,000 out of pocket max. Right? So again you hear the term out of pocket max. You think, hey, if I go to this out of network treatment center, right. The max I'm going to pay out of pocket is $5,000 because that's what my benefits say. But that's actually kind of a misnomer, that's misleading that out of pocket max. Because the truth of it is that insurance, uh, that health, uh, care provider can balance bill you because they're not in a contract with your insurance company, they're out of network. Right? So let's say you go to an out of network. It could be a treatment center, it could be a, any, any healthcare provider and they bill your insurance $200,000 and your insurance decides, no, no, we're going to pay 20,000 instead of 200. Well, you could now be balance billed $180,000. Right? So you know, obviously employers, they wanted to protect their employees for having that happen. And just Limit the charge. Right. Uh, that the, the provider can go after the patient for to in that hypothetical, $5,000. So how do you do that? How do you protect your employees? Well, you put these mechanisms and their benefits where you, you'll stay. We will pay additional funds, more than that 20,000 in that hypothetical. In exchange, please do not balance bill the patient, the 180,000 that is our employee. Please don't bounce bill. And there's a lot of policies with these, with these provisions in them and to the point where, you know, there's a whole company that I mentioned earlier, multiplan, their sole function is to administrate these. So when a, uh, health care provider enters into a multiplan agreement, oftentimes they say I'm in network with multiplan, which that's incorrect. You're not in network. You've agreed to not balance bill clients with multiplan benefits. Right. Uh, again, limit yourself to their out of network, out of pocket match. And so that's why a lot of people ask me, you know, why does this UnitedHealthcare or this Cigna policy pay me so well, 75% of bill charges when it could pay me $500 if they wanted to for this service? And the reason is you entered into that agreement. So the reason they're paying you 75% of bill charges is so you don't balance bill that patient. When you sign a multi plan agreement, you're stating, I will accept this reimbursement rate in exchange I will not balance bill the patient. And that's why they're doing it, because they have to. It's in the patient's benefits. And b, remember, the payer, it's not the payer's money, right? It's the employer's money. Right. Uh, it's these patient protection provisions do not, I mean they, uh, very rarely do they exist in fully funded or commercially funded policies. These are almost exclusively provisions and self funded health insurance. And that's what people really need to understand. And a lot of these, um, self funded policies, okay, these patient protection provisions against balance billing are not triggered through front end negotiations. So what Zeely does is after you receive payments, okay, we come in and we say, okay, which of these payments have these underlying provisions against balance billing and are therefore renegotiable for additional funds in exchange for the promise of, of not balanced billing. So that's what we do. We come in after the fact. And these can be significant sums of money. Right? Because you know, in that hypothetical with the 20,000 right. Where the, the insurance company initially uh, paid 20,000. Well a lot of policies you could come in and say all right we'll accept 50%, pay us another $80,000 and in exchange we will not balance bill this patient. The 180 will limit the patient's portion to 5,000 uh, which is their out of network, out of pocket max. And that's the underlying principle of what we refer to at Zealy as boost, which is what you mentioned earlier, our primary function.

Speaker A: That's super helpful. Uh, so let's just consolidate kind of two different pieces of information. So first you've got this fully funded and self funded. And just so listeners understand, fully funded means the insurance company is paying out of their pocket for the reimbursement. Whereas self funded, the payer is still involved, they are generally managing the plan but they get a uh, flat fee on that. And so there is no incentive technically for the payer to reduce the amount of bill charges outside of maybe a ah, promise they made to the plan that they're managing or the employer that owns a plan. So they don't really have as much skin in the game for managing self funded because they're not the ones paying. Would that be accurate?

Speaker B: That is accurate. Uh, and one component to understand is it's not even them you're negotiating with, you're not negotiating with the payers, they've actually outsourced that component to another third party.

Speaker A: Right.

Speaker B: That are referenced as TPAs. So not only do they, it's not their money, they're not even the ones negotiating. It's typically a third party administrator like the ones I mentioned, Multi plan Data Eyesight via guard tons the GCs. So those people, those companies, those third party administrators, those are the ones that have the financial incentive to reduce the rate because many of them, they get paid by the employer groups. Okay. As a percentage of the quote unquote savings. Right. So you know, multiplan, uh, has a financial incentive to push down the rate while the payer, they have no dog in that fight. There's no financial one way or the other. Right. So yes, what you state is correct, but there is one party does have a financial interest in keeping the rate low and that's the third party administrator.

Speaker A: Right? Right. So that's, that second piece is that third party administrator that comes in outside of the self funded payer management and as you said they are getting a, a percentage of let's say saved cost. So if you bill as a provider, if you bill $20,000 and multi plan or whoever pays 5,000, then they get a percentage of that $15,000 difference and that's their commission or that's their profit in the whole arrangement.

Speaker B: You got it? That was a perfect example. That's exactly how it works.

Speaker A: So then your opportunity and what boost does is they come and say, hey, this is a $20,000 service here. You guys only paid $5,000. And then you have this provision in your contract where we can, technically, because we're not in a contract with Cigna or Multiplan or whoever is managing your self funded plan, we can go to the patient and request that money. But you've stated to the employee that they will not be accountable for that cost because obviously that had happened in the past and everyone got really angry. And so employers looked for, for a way to mitigate that risk to their employees and keep everyone happy. And so this is where the third party administrators, the TPAs get involved. And so then you're able to go back and talk to them and say, look, we're going to bill the patient unless you provide a more reasonable reimbursement here. And then in that agreement then you guys promise not to balance bill. That closes the case. But these are also case by case. Right? So it's not like you do it for one employee of Google and then you're covered for Google forever. It's literally every Google employee that came to you would be individual.

Speaker B: Exactly. And it's case by case. And each patient has a different underlying benefit. Right. So in that hypothetical you said where the provider uh, built the uh, the patient's insurance 20,000 and they paid 5,000, that patient may in their underlying benefits. And we track all these. Right. So we have two databases. One database is where we store all the patients underlying benefits we've seen over the years. Uh, and the historical data of those reimbursement rates. And then the other one is a database where we just extract what are referred to as remark codes on EOBs that correlate with uh, those underlying benefits. So in that hypothetical, like I said, one patient, he may have a provision in his benefits that they have to re, they have to renegotiate to a maximum allowable amount from that 5,000 to 10,000. Right. They have to. Right. So they, you go to them and go, hey, this, this patient has this provision where you have to pay 50% of bill charges. In exchange, we won't balance bill, we'll limit them to their out of network deductible. And so we know that. Right. And a lot of times the third party administrator, since they have a financial incentive to do so, goes, well, you know, how about we give you 6,000 and you're like no, no, the underlying benefits say this, right? Like, so that's where the negotiation comes like, listen, we know we had this data, right? You have to pay 10,000 in an exchange. We won't balance bill. And then they go, oh yeah, you're correct, that isn't their underlying benefits, so on and so forth. Yeah, or, yeah, exactly. Or it could be as much as, you know, we've seen some that say you have to pay 90%. So it could go jump up to 18,000. Ah, right. And again in that scenario the payer will be like, how about 6,000? We're like no, no. Again it says in their underlying benefits you have to pay this. Right? And so again that's where that negotiation with the third party administrator is, uh, that function. And it's very data driven as you can see. Because if you don't know that going into that negotiation, then you're kind of flying blind. You don't know what they have to pay in exchange or what the maximum they have to pay in exchange for that promise, not the balance bill. And that, that's a very important data point.

Speaker A: And part of the challenge here is that none of this is templated. So you have a hundred page insurance contract and there's some minutiae somewhere you have a couple sentences that talks about this. And because it's not a template, it's worded differently every time. So you can't just do a search function and find this stuff. You literally have to read the whole contract to find the two to three sentences that mention this potential benefit that

Speaker B: are applicable to this scenario. Yeah. And oftentimes the language is even, even vague. So sometimes you're, you're reading the language and you have to kind of unravel it. Right. Um, and for us what we had to do is we, we had to kind of create, you know, this is the written word in a very long document. We have to take it and kind of create a database infrastructure. So you have row headers and column headers and you turn the written word into, instead of being, you know, typed into the database, it has to be a dropdown for each box in the database. So anytime new information enters, you have to create a new drop down in the drop down menu that can go into that box for that row header and column header. So it's definitely uh, uh, they don't make it easy. Right. You know what I Mean they definitely created a high barrier entry to know what are these underlying benefits so that I can get the maximum allowable rate, um, in exchange for that promise to not bounce bill. And again in the end it protects the patient from this balance billing. Right, which is the whole point, which is why the employer wants this provision in their employees benefits. Right. They don't want their employees getting these massive out of network, you know, invoices.

Speaker A: Right.

Speaker B: Because then what's the point of having a ppo, Right. It might as well just be an HMO if there's no if you're not truly limited to that. Uh, out of network, out of pocket max, you know.

Speaker A: Right, right. So that's clearly one example and the primary one that you guys focus on in terms of reimbursement, uh, information that maybe providers aren't aware of. Uh, do you have any other tips or insights to share around reimbursement? Things that programs might not know?

Speaker B: Yeah, again if you're out of network, uh, with any payer, especially the most important ones being United Aetna and Cigna, the most important agreement you're ever going to sign. Right. Um, is going to be either your multi plan agreement or any third party administrative agreement. They need to understand when they enter into one of these agreements, whether they're based on a percentage of bill charges or per diem, they really need to look at their data and say okay, historically speaking policies that had these patient protection provisions, what were they reimbursing and what am I being offered in in exchange for entering into this agreement? Uh, does it make sense to enter into this agreement at all? Uh, or should I just be negotiating them on the front end? Because keep in mind a lot of these patient protection provisions, in fact more so more patient protection provisions are negotiated on the front end through uh, depending on the pay or what are referred to as tpa, uh, thresholds like what was billed and what geographic region. There's a lot of factors that go into it, but most negotiations are actually done prepayment. Zealy focuses on post payment negotiations, but a lot of it. And, and for our full service clients we do these prepayment negotiations as well. Very important. Okay, these, the, when you enter into these TPA agreements, what was I getting reimbursed before, what will I get reimbursed after? And a lot of times when we bring on an account we do an analysis, we actually have to unwind a lot of the contracts they've already entered into, whether they be multi Plan or PNCs or any third party administrative agreement, First Health Network or renegotiate them on their behalf to make them more advantageous. But it's very important, I think it's uh, very overlooked that part uh, of people's operations, they really need to focus on those. What was it before, what was it after, what changed, what benefits did we receive, so on and so forth.

Speaker A: So as a provider, what would be the advantage of doing the agreement upfront? Prepayment versus post payment.

Speaker B: So well, prepayment negotiations. If you can get your claims to go into one of those agreements and they're good, it's far simpler. Right? You know the rate, right? Let's say you enter into a multi plan agreement that says I will get reimbursed second 75% of bill charges on any policy that you know is administered by multi plan the patient protection provisions, well then you know that's what you're going to get reimbursed. One thing people need to understand though is just because a policy, let's say has the multi plan logo on on it doesn't mean it's going to get priced. There are thresholds and rules of that you don't know about and they don't put that in the document documentation of what claims they can pick up in what scenarios and what claims they can't. So a lot of policies with patient protection provisions you'd be like hey, this clearly has, you know, it's got the multi client logo, it's got you know, an administrator logo of one of these companies that administrates these patient protection provisions. But they're not pricing the claims, they're, they're pricing much lower. And in that scenario you're only option is post payment negotiation because the patient still has that patient protection provision against balance billing. It's just not being triggered on the front end. So you need to open up negotiations on the back end after post payment negotiations. And in fact oftentimes if you look at EOBs they will specifically state on the EOB in the remark codes at the notes at the bottom of the eob, if you accept this payment, you cannot balance bill this client. So they're saying even though they put money in your bank account, it's actually not the payment, it's an offer of payment. That's what I always tell people, okay, that's not the payment, that's an offer of payment. If you do nothing, you're accepting that offer payment and therefore cannot balance bill. Right. Uh uh, so um, you know, you need to go back and negotiate, say no, I Don't accept that offer. Right. They put money in your bank account and they, and then, you know, put a couple words on an eob, right. And you're supposed to do. See what I'm saying? So, so you have to go back. No, I don't accept that offer. Actually, this patient, you need to pay me 70% of bill charges according to their underlying benefits. I'll accept that offer or I'm going to have to balance bill this patient because this is simply not a high enough reimbursement for me. You know, a lot of people, they're losing, uh, on those. Some of those payments are so low, they're, they're losing money treating patients. Right. And that's obviously not a sustainable business model.

Speaker A: Yeah, exactly. So the advantage to negotiating prepayment is just cash flow certainty, probably reduced cost, and trying to follow up on post payment negotiations. Would that be accurate?

Speaker B: That's exactly correct. Yeah. Ah, if you can. Unfortunately, a lot of them are going to not even allow you to do the uh, prepayment negotiation negotiations.

Speaker A: Okay. So from your perspective, you're looking at what the advantage is. Are we getting paid more by doing post payment negotiations or is there an advantage? Do we have enough patient volume here? Does it make sense to engage in agreement and just have more certainty around what we're going to get prepayment?

Speaker B: Exactly. Depending on what they're, they're going to, uh, they're willing to negotiate on the other side prepayment. And a lot of you can use your post payment negotiations in your ammunition when negotiating your prepayment negotiations. So you're like, hey, historically speaking policies with these patient protection provisions, we've been able to negotiate them post payment to these rates. We will not accept anything below these rates on the front end negotiation. Now again, they may enter into an agreement and then you start submitting claims and none of those claims get priced by that agreement. And that's because, uh, your billed amounts may be outside their, uh, unwritten thresholds. Unwritten to you. Right. Uh, so you could be, you know, billing someone $5,000 a day and if you're in a 60 agreement and $3,000 happens to be, which would be the payment in that scenario happens to be outside of the threshold that that third party administrator can pick up. They can't even pick up the claim. And they want to, they want to pick up the claim because they get paid quote, unquote as a percentage of the savings. So, you know, it's not that they're not picking up because they don't want to. They're picking it up because it's the agreement they made with that employer group or through that payer that TPA can't pick up that claim. So it goes to a different, what we call downstream pricer. Right. And typically downstream pricers are the ones you're doing post payment negotiations with because they simply the threshold on the front end prepayment negotiation wasn't met by your what the outcome of the paid amount would be. And there's a lot of complexity there, as you can tell.

Speaker A: Yeah, it sounds like it. So the downstream payer is still not uh, necessarily the plan administrator or the self funded plan, the employer themselves. This is yet another party that's involved.

Speaker B: Exactly. It's a different third party administrator. So a lot of times a claim will quote unquote, what we call bypass a uh, front end negotiator. Right. Typically the one that it's bypassing is actually Multi Plan. And the funny thing is when it typically when a, when a claim bypasses Multi Plan and goes downstream to a different third party administrator, oftentimes that other third party administrator is a, is a subsidiary of Multi Plan because Multi Plan went out and bought like a lot of the other downstream uh, TPAs. So, so, so you may even be negotiating with someone who is working at a subsidiary of MultiPlan. It's a very strange web, uh, uh, that you know the way it's structured.

Speaker A: Right. And then these downstreams operate in a similar business model where they get a percentage of saved charges.

Speaker B: That is correct. Yes, exactly.

Speaker A: Okay. All right, all right. Fascinating.

Speaker B: Yeah. When I first started reading about this, I'm like this is crazy. I can't even believe this got so complicated. Why is it so complex?

Speaker A: Right.

Speaker B: You know.

Speaker A: Yeah, uh, uh, so stepping back a little bit just from a general sense and you guys obviously are dealing primarily with out of network in this respect. How do you recommend programs think about out of network versus in network?

Speaker B: Yeah. So obviously, you know, I think a lot of people, again there's certain payers, Right. That don't have very many of these patient protection provisions because they don't sell as many of them to their quote unquote ASO clients or they just don't have that many ASO clients. So uh, you know, I think a lot of people say they make broad statements like the, the, the space is going in network work because that's what the payers want. Well, yes, you are making a correct statement when you're talking about fully funded or commercially funded policies that are the payers uh, money and oftentimes I tell people, you know, if you have a, a PPO and it's fully uh, funded right by the payer, where the, you know, the actual person paying the money is a United or Cigna, it's almost pretty much like an HMO you should probably go to in network provider. You're not going to have very many uh, patient protection provisions against balance billing. Uh, so you're really exposing yourself to liability when you go to an out of network provider being balanced billed by that provider. Right. So I always tell people, you know, yes, uh, uh, the market is shifting for policies that are fully funded but when it comes to self funded, right. There is no financial incentive for the payers to be directing those claims, those patients to in network facilities. Those are to me a self funded PPO is kind of more like a true ppo, right. Where you can go to an out of network provider and be protected against being balanced bills and have good coverage and they'll get reimbursed well and so on and so forth. So I think it's a payer specific thing, you know, like who do I want to be in network and what geographic region. Who do I want to be out of network in what geographic region? Uh, and a lot of that has to do with how many commercially funded policies versus self funded policies from that particular payer are entering treatment under my care. And that's, it's got to be a very data driven decision. And then eventually uh, you know, keep in mind, currently speaking a majority in our vertical of in network contracts are per diem rate. And we're just, just getting into the value based care model of the contracts. And it's very hard because of outcome tracking in our sector as you can imagine. So even the current in network contracts I think in five to ten years from now will quote unquote be outdated. They will be. We're going to have to shift uh once, once more data comes in, once more um, you know, outcome tracking and we can do a better job of this structure those agreements as quote unquote value based care models. So uh, which is a completely different topic that definitely we should not be discussing. What I'm just bringing that up as if we're talking about how the market's going to shift in the future, whether it's going to be in network versus out of network. What I'm saying is it's payer specific and then even when you certain payers, you're shifting to this in network model in addition to that, that in network model will be shifting to a value based care model in the long run.

Speaker A: Yeah, and curious on that whether you're looking at network contracts or rally based care contracts. So if we go into contract with Cigna and they've got some fully funded plans, they got some self funded plans, does our contract with Cigna change or does the reimbursement change depending on if it's fully or self funded through them?

Speaker B: No, it's a blanket contract. So then those really. Let's say you enter into a CIGNA agreement inpatient, let's just say residential to make the math easy. Uh, their Cigna says we'll pay you $1,000 a day in network. It doesn't matter if it's commercially funded or self funded. So if the day before 95% of your Cignas entering treatment into your facility were self funded and paying you $3,000 a day, and then the next day you sign an in network contract and all of a sudden 95% of your payments went from $3,000 a day to $1,000. That you have to make sure, you know, you're taking that into account. Right? Can I operate and provide the level of care of services that I was providing yesterday to this patient population? Right? Because you know, most of these places, they take the money that they generate and they reinvest it in the care that they're giving the patients. So if that dramatically drops, that could affect patient care. So it's definitely a, uh, you know, you need to do, it's. This is such a data driven business. You really need to do an analysis and not make blanket statements. Blanket statements. What I, in this sector are, have, have really harmed a lot of businesses, right? You know, like, oh, we, a blanket statement I've, I've heard is we just can't operate rate out of network. Right? And I'm like, it's just not, doesn't work for us. And I'm like, well, you know, I think you need to dive in specifically each payer, each uh, you know, is a commercially funded seller, so on, and do a deep dive into your data. A lot of my, uh, providers are hybrid. They're uh, in network with, you know, a lot of them are in network of Anthem Blue Cross because again, uh, they have the least number of um, patient protection provisions. But with places like, you know, United Cigna and Aetna, it's a harder decision to make and you really need to do a deep dive on your data before, uh, making that decision.

Speaker A: Yeah, agreed. We, we talk about that on the show quite a bit where you really have to understand your, your data and what's going to work for you, especially when you do contract negotiation. And just from a simple point, you know, what's the reimbursement? What's the, the volume of patients that you're seeing from that particular payer source and then what's your cost per day? What's your operating cost?

Speaker B: Uh, exactly.

Speaker A: That's going to ultimately determine your ability to be financially viable with any contracts that you're potentially, um, negotiating.

Speaker B: Yeah, yeah. And it's so important I tell people, you know, those agreements you sign, whether they're in network agreements or third party administrative agreements, do not sign those without a lot of due diligence on your own data. And then you know, kind of write some pro formas based on if I do enter this agreement, how will my financials, uh, change. Right. And, and try and kind of don't just enter into a lot of these people enter into these agreements without really doing a deep dive in their own data and then you know, doing projections on what would happen if I enter into this agreement otherwise. Right. And kind of see those two paths. What are the pros and cons of entering the screen? Whether again whether that's a, um, in network agreement or a third party administrative agreement.

Speaker A: Yeah, I really agree with you because that blanket statement part doesn't help. You know, we've had providers that say, well, we're never going to go in network because we don't get reimbursed enough to provide the level of care that we don't provide. Well, sure, but are you going to get enough patients in? Yeah.

Speaker B: Which is so true. Right? Yeah, yeah. Again you have to. Yeah. That black blanket statement is just as bad as the other blanket statement. Right. They're both uh, that you should definitely never say that because there, there is a model for sure. I mean I have plenty of clients who are in network with every single payer and they make it work and they provide quality care. And we're, I'm already talking to them about, you know, long term how are you going to adjust to the value based care model. Right. And kind of projecting out what would that look like? And, and so, and all of them, there are ways to make them work, but it's just everybody's different. You need to look at your data, you need to look at your treatment models and all that and say what works best for us. All right. And it's very client, uh, specific. Something that works for one client certainly, uh, would not work for another client. And geography matters a lot with that as well. Right? What policies are what geographic regions and so on and so forth. And what do they reimburse in those geographic regions, you know, for different types of services?

Speaker A: Yeah, right.

Speaker B: Very, very data driven. Bottom uh, line was I tell everyone you need to be taking a constant data driven approach to any decision you make in the sector. Because one small decision, what you think is a small decision could have a major impact on your business.

Speaker A: Right? Yeah, that's exactly right. M digging into the negotiation a little bit. I'm just actually curious so specifically with what you guys are talking about around boost and these patient um, protection provisions. So multi plan gets involved. Let's use our $20,000 example again. So you bill $20,000, multi plan pays you 5,000. You know, what's the incentive there? Because obviously you're coming to some kind of compromise. Multiplan is not going to pay you 20. Usually you're not going to accept 5. Can you explain that process of like why can't you say hey look, we're going to charge $20,000 and if you don't agree to that, we're going to balance bill the patient. How does that conversation go?

Speaker B: So yeah, so one multi claim doesn't want to lose that claim. Uh, uh, or any third party administrator if you're like oh we're, we're going to go back to the payer and say, you know, we're going to balance bill and they're going to be like well uh, you know, we're not going to be routing claims to multi plan anymore. So there goes their percentage of the savings. So they have an incentive to negotiate because they don't want to quote unquote, lose the claim. Right. Because then that's it. They make zero. It's no longer their claim. They didn't save anyone anything and they didn't protect the patient. So, so that's one side. Now on the other side, what's the benefit to the provider of not balanced billing? Is that the. Obviously in that hypothetical, let's say, you know, you just uh, bill the guy's insurance 20,000, they pay you 5,000, you invoice the patient 15,000, he may not have it, he may default. The default rates on that are really high. Uh, on balance billing and B, he will have a negative, he may have a negative impression of you. Right. The financial components and also these patients, a lot of them, the financial stress can trigger their underlying mental health and substance use disorder conditions. Right. So you don't want to do that either. Right. It can actually harm them from a clinical perspective. So, so to the providers I say, listen, you know, you're gonna a, the patient's gonna uh, you're gonna get paid more than uh, what you initially got paid. One, you're not going to go after the patient and create like this, you know, stressful environment where they'll have a negative impression of you. And next time if they need help, guess what, they're not going to reach out to you. You, if they have this negative impression of you. Now if you make the effort and you go, listen, you know, I don't need the whole 20,000 but you know, hey, uh, third party administrator, multi planner data. I said, or whoever, maybe I'll take 10,000 and in exchange I'll limit, let's say that the guys remaining out of network out of pocket max was a thousand dollars. And you say I'll limit myself to that thousand dollars and just invoice him that you get 11,000. The patient, rather than being on the hook in that scenario for 15,000, they're only 1,000. Right. So to them it's like, wow, look at that, big difference it made to them. And really you have to take that into account. Now they've had a good experience. They were limited to their out of network out of pocket max, which when they hear those words, you know, I hear those words and I think that's the limit. That's my out of pocket max. And so, so which was their expectation, if it falls out outside their expectation and they have this huge financial burden on them, A, it could trigger their, the exact reason they sought care. Right. Because of the stress of that financial burden. And two, uh, you know, they, they won't call you next time they need help. So it's, it's definitely, you know, I think it's advantageous to all parties in that scenario. And of course the employer group that initially bought that for their employee is getting that benefit as well. Right? Their employee's not getting that financial burden. They did that for a reason. Yes, they paid a little bit more, but they paid a little bit more to protect their employee. Right. And, and they're getting so much money into those. Remember when you pay your premiums on a self funded policy that's going into a pot that the employer controls. So, so they have a lot of funds in that, in that pot. And if they can use that to protect their employees, you know, that's what they signed up for. That's, that's the whole purpose of it. It was them that asked for these provisions to begin with, the employer groups.

Speaker A: So yeah, that's a great exercise.

Speaker B: It was set up for this reason. Exactly.

Speaker A: So we've covered a lot of intricacies and probably making people's heads spin and all the fun stuff with third uh, parties and secondary third parties. Anything else that you want to add as we wrap things up here that you think would be helpful for people to know?

Speaker B: Yeah, again, you know, it is. This is the message I tell everyone. It's, it's all about the data. Right. So be very mindful of your data when making these large decisions. We come in and you know, this is uh, this post payment, it could be millions of dollars in additional revenue. So obviously definitely pursue it. Right. That you're probably sitting on significant sums of money but also pursue front end agreements first look at the data. Like for us we always say, you know, let's look at the data. Uh, how many of these claims that were subject to this post payment negotiation, had you been in a front end agreement, how many of them would have fallen, quote unquote within the thresholds of that agreement and would the reimbursements have been higher, uh, had it been that way? Right. And then that, that way you can make a very educated decision on should I enter into one of these front end third party administrative agreements or should I continue just doing post payment negotiations?

Speaker A: Yeah, great advice. And I always recommend to providers to hire a third party consultant for review for any major initiatives for like a single contract or something. It's up to you. But a lot of people try and hire someone with experience doing these negotiations, negotiations and that's great. But I would rather have someone come in like a billing company or someone like you guys that have a lot of background information that can compare 400 policies, you know, uh, across my markets and tell me what the averages are. At least we're going in empowered we can know what some contract provisions to look out for. I mean that's.

Speaker B: Yeah. And like us, that's a very good point. Right. We have aggregated data, so we have aggregated data from billions and billions of dollars worth of claims. Right. So we know, hey, in this geographic region, these policies pay this amount. Out of network, these policies pay this amount. These are the agreements, these are the average rates of in network contracts in this geographic region. These are the average rates um, on national contracts versus regional contracts. Like again, data driven approach to making these decisions. And aggregate data is so much so more useful. Right. Because you, you're, when you're limited to your own data. You don't get to see all of the other information that's out there. Like for us, the reason we were able to get so much data on patients underlying benefits is because we work with so many clients. Billions and billions of dollars of claims, which means tens of thousands of different policy types with different patient protection provisions and the underlying benefits being stored in our database that we can then query and say okay, this is a like kind policy with the exact same underlying benefit type. What if historically what is a, what does it state in the underlying benefits and have the third party administrator been adhering to these underlying benefits historically speaking and, and how do we hold them to account to make sure they are. So it's definitely, you know, for us we get hired, you know, that's how we met. Right. So you have some of the biggest clients in the uh, US Uh, we also have some of the biggest facilities in the US and that's how we met shared clients. Uh, uh, one very large share client uh, initially introduced us I believe. Yeah. So um, yeah so the, the more sophisticated companies are getting, there's a lot of, as you've probably noticed, a lot of sophisticated operators are getting into this sector. We are becoming more and more, they're coming to us and saying hey, you know, we have these questions and, and they're get, and they're more complex, more you know, how uh, should we scale, how should we structure these agreements, so on and so forth. So, and of course again we have the aggregated data and we can help. But, but when it comes to post payment negotiations, that's a no brainer that you're sitting on free money. Right. Like if you're not balance billing your patience now, right. And, and we can make sure you don't and get you more money. That, that one's a no brainer. Everybody, almost everybody who reaches out to us and does the uh, you know, we, we do an analysis, we do a free analysis everyone to say how much additional revenue are you sitting on? Because luckily we can you know, extract all the policies that have those patient protection provisions and then say okay, not only do these, all these policies have these patient protection provisions, this is the maximum allowable amount on post payment negotiation. Therefore you're sitting on Approximately, you know, $2 million in addition to revenue. We can tell people that ahead of time before the negotiation process even begins. And so that gives them a more educated, you know, if we do someone and we're, it's like uh, you know, it's only 50,000 more dollars and you're a huge company, they're like, all right, whatever, do it right, because it's free money again.

Speaker A: Exactly.

Speaker B: You know, they're not super excited. But if it's millions of dollars, which it has been historically, we've had quite a few clients that they were sitting on, you know, because you can go back a year, uh, on a lot of these, on the patient protection provision. Some. Some limit you to six months. Uh, but a lot of them, they say, you know, if within a year, you don't balance bill or you don't, um, post payment, negotiate for additional funds. You cannot balance bill or postponement, negotiate for additional money, you've lost that window. And some, depending on the underlying benefits, limit that to six months. But typically it's about a year.

Speaker A: Yeah, yeah, those are all great points. I always say to people, you can hire the best payer relations person in the world or the best marketing director in the world, but at the end of the day, they've worked for maybe one or two other providers, they've seen 20 contracts, they've managed at most maybe 10 million in ad spend, where, as you said, you probably process billions of dollars of claims. We've run billions of dollars of marketing spend. So just the sheer volume and access to that is significant.

Speaker B: Exactly. Yeah. It cannot be replicated with a smaller data set. It's just not. It's not possible.

Speaker A: You know, so if people want to contact you or contact Zealy, what would be the best way to do so?

Speaker B: Yeah, you can always, always, uh, a. You can email us@infozly.com, you can visit our website. There's. There's a demo application in there you can just fill out. Also, you can just call our phone number, 1-800-478-0233, and speak to a Zealy representative. And. And then we set up a demo. Typically, like I said, demos, 30 minutes. Then we do, you know, the analysis and we tell you, here's your. You know, here are all the claims. We present all the claims. Here's all the claims that you have in your historical data that are renegotiable for additional revenue. This is the additional revenue you'll get on each one. Would you. Would you like to proceed? And pretty much the answer is always yes, because like I said, it's. It's. It's found money, it's free money. So, uh, unless they're, you know, they're like, no, we need to balance, bill everybody and go after them, which has never happened. Right. So, uh, because if you want to go out of business. That's a good way. Uh, you could easily get additional revenue by negotiating with their third party administrator.

Speaker A: Right. Well, I really appreciate the time, Ali. Um, fantastic information for all of our guests out there. This is Recovery Executive Podcast. I'm your host, Nick Jaworski, and we'll see you next time.

Speaker B: Okay, thanks again.