MNRP Maximum Non-Network Reimbursement Plan

Posted in August 2015 by Dana Ellis

MNRP was primarily used for “Retiree Plans” as a way of lowering the out of pocket costs for Retiree’s or Medicare age members much like Medicare does, and the “New Non-Network Reimbursement Program" was Announced.

I believe this is one of the guides for the methodology for payment for ASC’s, Surgeons and physicians that were out of network.

The program effects payment for out of network claims for “Hospitals (inpatient and outpatient), no its or because it doesn’t always apply to both… Free-standing ambulatory surgery centers, Free-standing radiology centers, [and] Free-standing laboratories.”  United Healthcare included in the announcementIt is our hope that the implementation of this program will encourage more out of network providers to join our network”. 

MNRP is also disguised by the words “Webstrat” or “Berges” that all use the same system of 110% to 140% of Medicare allowed amounts based on the location of where the services were rendered.

Pricing and new “names” for methodologies continue to grow and reimbursement has continued to drop and at a declining rate for at least the last two years.

Most carriers base payment for out of network claims for commercial plans by:

  1. Looking at the percentage of Medicare fee schedule
  2. Determining if the ASC is contracted
  3. Using a fee schedule developed by the carrier
  4. 50% of the billed charges or allowable amount based on the demographic area.

According to some carriers, MNRP creates a maximum allowable reimbursement for out-of-network services using rates and methodologies established by Medicare.

The calculation for this “methodology” is typically the Centers for Medicare and Medicaid Service (CMS) Rates multiplied by factors.  These in my opinion are improper methods for determining UCR for out-of-network claims.  

While United Heathcare has switched from Ingenix to Webstrat, from what we have seen with reimbursements they both work the same and appear to have the same problems with errors and pricing out-of-network claims.

It has been mentioned several times to our staff that MNRP is in the patients “Plan Booklet/SPD”. However, when we have obtained the patient plan description booklet, there has been nothing about MNRP.  The only statement we have found is “if no other methodologies can be used, another pricing system will be used for out-of-network claims”.  There are “other” methodologies that could be used, but are being avoided to lower the cost of paying the claim.  When considering what some insurance carriers are doing, one may ask themselves if a line has been crossed.

The following are some points that we use in our appeal process for incorrect reduction on claims:

  • Address Webstrat pricing system
  • Point out that the patient is not Medicare eligible
  • Include the patients allowed amount for out of network claims
  • Bring to their attention that MNRP is not in the patients SPD
  • Site class action suit(s) for example; American Medical Association v. United HealthCare (S.D.N.Y),588 F.Supp.2d 432(2008)

Unfortunately, what started out as a good idea to assist Retiree/Medicare patients with healthcare costs is now being abused and misused. It is being abused and misused to the point where no patient will benefit from seeking care because of their out of pocket and non-covered charges will increase along with their premiums.

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