Some Self-Funded Plans May Reimburse 50–100% of Billed Charges. Would You Know If Yours Did?
If you perform high-value procedures, there is an important question worth asking:
How do you know whether your out-of-network claims are actually being reimbursed correctly?
Not simply whether they were paid—but whether the reimbursement was consistent with what may have been available under the patient’s health plan.
At Clear Management Group, we have seen certain out-of-network claims involving self-funded employer plans and favorable usual and customary reimbursement provisions ultimately pay 50%, 80%, and, in some cases, 100% of billed charges.
Those results don’t happen on every claim.
But if one of your claims had that kind of reimbursement potential, would your current revenue cycle process identify it?
How Out-of-Network Medical Billing Can Identify Underpaid Claims
Imagine your practice or surgery center submits a $100,000 claim. The carrier processes it, sends payment, your billing team posts it and eventually closes the account.
But was the most important question ever asked?
How did the carrier determine the allowed amount?
Depending on the patient’s specific plan language, out-of-network benefits may be calculated using usual and customary charges, reasonable and customary charges, Medicare-based methodologies, proprietary pricing schedules or other plan-specific provisions.
So when a carrier pays a fraction of billed charges, how do you know that payment represents the reimbursement actually available under the plan?
This is where traditional medical billing and specialized out-of-network revenue cycle management can look very different.
A traditional billing process may ask:
“Did we get the claim paid?”
Clear asks:
“Was it paid correctly—and is there a legitimate opportunity to pursue additional reimbursement?”
We have worked claims where continued review, customized appeals and escalation resulted in reimbursement reaching 50–100% of billed charges. These outcomes are not guaranteed and do not apply to every claim.
But it raises an important question:
How many claims has your organization closed simply because the insurance company issued a payment?
How Self-Funded Health Plans Affect Out-of-Network Reimbursement
Many physicians know whether a patient has Aetna, Cigna, UnitedHealthcare or a Blue Cross plan.
But do you know who is actually funding the patient’s benefits—and how their out-of-network reimbursement is determined?
Certain self-funded plans may be governed by ERISA, making the underlying plan documents and benefit language especially important when evaluating reimbursement.
Does your team know:
- Which patients have self-funded plans?
- How their out-of-network benefits are calculated?
- Whether the initial payment appears consistent with the plan?
- What to do when the reimbursement doesn’t look right?
If those answers aren’t clear, there may be an opportunity worth investigating.
Why High Value Out-of-Network Claims Require Specialized Review
You already have the patients.
You’re already performing the procedures.
You’ve already invested in the clinical team, equipment and overhead.
So what if the opportunity isn’t necessarily about increasing volume—but about maximizing the reimbursement opportunities already in front of you?
For pain management, spine, anesthesia and surgical facilities submitting high-dollar claims, even a relatively small number of underpaid claims can have a meaningful financial impact.
Clear does not promise that every claim will pay 50–100% of billed charges. No one can responsibly make that promise.
Every claim is different.
What we can tell you is that we have seen certain qualifying claims reimburse at 50%, 80% and sometimes 100% of billed charges.
The more important question is:
Do you have claims with greater reimbursement potential—and is anyone identifying them?
What Would You Find If You Looked at the Numbers?
If you discovered that even a small percentage of your out-of-network claims had greater reimbursement potential, what could that mean for your practice or facility over the course of a year?
Would it be worth finding out?
Clear offers a complimentary revenue evaluation of a sample of your existing claims, EOBs and billed charges to identify potential reimbursement opportunities.
We’re not looking to tell you every claim should pay 100%.
We’re looking to answer one question:
Are there claims in your current revenue cycle that may be worth more than you’re collecting today?
If we identify opportunities that are being overlooked, would it make sense to explore how Clear could help you capture that additional reimbursement going forward?
Let’s Start With the Numbers
Request a Complimentary out-of-network Claims Evaluation
Allow Clear to evaluate a sample of your out-of-network claims at no cost and show you what we see.
Then you can decide whether a conversation makes sense.
Would it make sense to let us take a look?
Reimbursement results vary by payer, health plan, plan language, procedure, patient benefits, billed charges, applicable law and individual claim circumstances. Prior reimbursement outcomes do not guarantee future results.
