Scenario 3: The entity and the payer enter into an agreement to pay a percentage of the fees charged. LOA/SCA statements will be reimbursed at 40% of the charges. Scenario 2: Suppliers and payers enter into an agreement that the payer pays a rate of $1500 per day as long as another authorization is obtained. The LOA/SCA does not specify the level of care at which care can be provided. The provision of a higher level of care means that a provider must be compensated at a higher rate than the level of surgical care. Providers, particularly long-term care providers, should negotiate reimbursement for many levels of care. In their other letters of authorization, payers will indicate the level of care they will approve so that the calculations for expected payments are simple and simple. The LOA/SCA must be clear on his face that Medicare Part A benefits were exhausted prior to authorization and that the payer who performs the LOA/SCA is paramount. In the absence of a clearly defined level of care, most payers will only approve of the level of medical care. A patient may need surgical care after admission, but may need a telemetry or intensive care unit during their stay. In most cases, hospitals negotiate with the payer to perform an LOA/SCA with a defined reimbursement rate that is acceptable to both the payer and the supplier. Most receivables are negotiated either to pay per day, by pricing plan, or percentage of the total fee charged. It sounds pretty simple; However, LOA/SCA is not a guarantee of payment.
There are many cases where claims are underpaid or rejected, although a supplier has registered an LOA/SCA. Below are some scenarios that suppliers often find. Instead of running many LOA/SCA, suppliers should aim to go to the network with insurance payers, especially when suppliers notice that they are exporting a large amount of LOA/SCA with a particular payer. It may be in the supplier`s interest to enter into contract negotiations. This will allow for a single payment unit and allow both the supplier and the payer to be transparent about how a claim should be assessed and paid. Although LOA/SCA does not have a payment guarantee, it helps the supplier know what to expect and streamlines the claims management process. LOA/SCA, mutually agreed, contains a legal document that describes the intent of both parties and provides the necessary supporting documents to appeal if the payment is incorrect. Hospitals often enter into agreements with an insurance provider (LOA) and single case agreements (ACSs) when the provider is not considered a network provider with the patient`s insurance plan. LOA and SCA are usually performed at the time of admission when the patient submits a non-contract insurance plan. However, they can be performed before admission if the patient is ready for transfer or at any time during the stay. In order to expedite the refund, a copy of the LOA/SCA must be submitted with the application. Suppliers should contact the payer`s representative who performed the LOA/CAS in the event of a problem.
Agents have limited information, access and understanding of LOA/SCA and, in most cases, maintain the position that the claim was properly paid.