Setting the Table for Insurance Payers

Final article in a 4-part series designed to offer small practice providers tips on improving their administrative and clinical operations.

It is not a stretch to say that payer relations are paramount to the success of your practice. And, fortunately, there are ways you can improve how the reimbursement process works with a handful of tactical strategies that will create a more inviting place setting for health plans, while keeping business courteous and retaining your position at the head of the table. Here are some tips for enhancing your payer relations:

Manage Contracts
It is important for small- and medium-size practice managers to know the policies and fee schedules of health plans to ensure they are being paid correctly. Most coders and billers are not aware of the agreed upon rates for procedures, or whether the contract is paid by relative value unit (RVU), flat rate or some other fee structure. Knowing contracts means you can ensure the practice is getting paid what it deserves and that codes, RVUs and prioritizations are aligned. And when the contract is up for renewal, don’t show up empty-handed. You will want to have concrete data at your fingertips that shows cost of services and profits from care provided to patients.

Track Payments
Denials eat up time and resources. The first step in finding a fix is to determine what types of denials you are getting most often from the top two or three payers, such as bundled services that were billed separately or incorrect codes, for example. By tracking these patterns, you can go back and change habits through education (physician documentation, coding errors, etc.) or decide if a denial was inappropriate and appeal the decision. If you disagree with a policy change or denial, bring it to the attention of your representative. If it needs to be escalated, contact the plan’s medical director. Whichever direction an issue takes, claims resolution takes time, so it’s a good idea to appoint a lead to chart, pull and review the documentation for the least amount of disruption.

Close the Communication Gap
When it comes to improving payer relations, there is no substitute for direct communication. Get to know your representative. Issues that are addressed quickly tend to remain manageable. Your health plan contact can answer questions quickly or put you in touch with resources that can help. Moreover, learn to speak the payer’s language. Delivering information on clinical outcomes, profitability and service volume will earn you respect, lay the groundwork for dialog and make clear the goals you want to achieve.

Having a solid understanding of the industry by being armed with data, whether to negotiate a contract or settle a dispute, and clearly communicating expectations and goals will keep the reimbursement process running smoothly. Likewise, these actions will set the table for future business and partnerships with payers.

Whether it’s arming your practice with claims rejection data or helping to improve the accuracy of your claims submission, Emdeon simplifies the everyday tasks of physician office staff, enabling you to create claims online or submit them through a practice management system. Our reporting and analytics dashboard allows you to track claims from submission to payment, identify and correct rejections, and be made aware of the top reasons for rejections so that future claims can be submitted accurately—and help you get paid faster.

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