We are seeing an increasing number of challenges to payors cost saving measures of retroactively changing the payment methodologies on unpaid claims for out-of-network providers involved with audit activity. For instance, if payors audited a 2015 claim and didn’t resolve the claim until 2017, the payor will pay 2017 rates instead of 2015 rates. More recently, payors have based their out-of-network rates on the benchmark set by Medicare, but have not explained the reduced reimbursements. The lack of payor transparency as reimbursements slide is frustrating to out-of-network providers who have little notice or opportunity to react.
