Follow 3 suggestions to receive proper payments
To avoid seeing your reimbursement drastically reduced by payers, do the following:
• Have a copy of the contract, and reconcile remit payments.
Many providers don’t have the payer contract and fee schedule at their fingertips, says Lolita M. Jones, RHIA, CCS, principal with Lolita M. Jones Consulting Services in Fort Washington, MD.
"You don’t have someone reconciling remit payments to make sure you were paid what the contract said," she says. Any payment could be incorrect, Jones warns. "Some [surgery managers] say they don’t have time, but they can’t afford not to do it," she adds.
At Specialty Surgery Center in San Antonio, managers spot-check contracts and explanation of benefits (EOBs) on a monthly basis, notes Steve Blom, administrator. Pick a payer, take 10 EOBs, and compare them with your contract, Blom suggests. "A little bit of oversight is more work, but it’s worth it," he says.
Have a good analysis of reimbursement on a grid for your business office staff to use so they easily can review what you’re supposed to be paid, particularly on implants, Blom notes.
Additionally, obtain a good billing system, and use the system to its full potential by keeping the contractual information current, he explains.
Blom’s facility uses Prescient Vision system by Prescient Healthcare Systems. One of the important aspects of the billing system is in case cost analysis, because it’s imperative to know your cost before you start negotiating your contracts.
• Be willing to fight, and get physicians involved.
When you receive a vague letter from a payer, make sure you understand it, suggests I. Naya Kehayes, MPH, CEO and managing partner at Millennium Health Consulting in Issaquah, WA. If the payer hasn’t given you all the information you need, contact them to ensure you understand the financial impact, she advises.
Ask the payer if you need to send a termination letter to prevent them from changing the methodology. "Strategically, they notice that you’re willing to terminate, without really terminating," Kehayes says. If the payer says you don’t need to send a termination letter, immediately send a certified letter to the insurance company stating, "We are in the process of evaluating the financial impact, and we don’t agree," she advises.
If you determine a payer’s changes will result in loss for you, immediately start renegotiating the contract, Kehayes recommends. Go to you board, and determine if termination is an option, she adds.
Keep in mind that, depending on your state, payers may be reluctant to terminate a contract if they have to notify all their members, Kehayes says. "Sometimes, they’re doing everything to avoid termination. In other states, if you want the insurance company to move on a contract, termination is the only way to do it. The issue is payer-sensitive and state-sensitive" Kehayes says. "It depends on their philosophy," she adds.
When Decatur (IL) HealthCare stopped being reimbursed for second procedures during the same case, Marla Christensen, CPC, office manager/coder, sent the payer a request by registered mail and asked for a response within four weeks. As Same-Day Surgery went to press, the issue had not been resolved and they were being reimbursed for second procedures on a case-by-case basis.
Take the time to write detailed letters with specific questions, and know your rights as far as what payers have to provide to you, Christensen suggests. Make insurance companies defend what they categorize as being over "usual and customary charges," she advises. Ask the payer for a definition, Christensen suggests. "It means something different for every payer."
Question the payer about its pricing program, Christensen adds. For example, are prices set for a region or is there one for the entire country? You have to ask specific questions, she notes. "They know it’s a lot of work. If you have a large practice, it’s difficult to do on every case," Christensen explains.
In Blom’s case, the payers had moved cataracts, which make up half of the center’s volume, from Group 8 reimbursement to Group 4. The process of negotiating with the payer took six months and got "pretty nasty, with us threatening to terminate each other," he says. The center’s managers continued to move up the chain of command with the payer, and their physicians began writing letters and making calls, Blom continues.
When negotiations become drawn out more than six months, you may need professional help from a consultant who has extensive experience in contract negotiations, he suggests.
When one practice examined why it was losing $90,000 a month over three months, a payer representative called the business office and said they no longer were paying for multiple procedures. The business office didn’t communicate that change to the administrator or physicians. Fortunately for the ASC, there was language in the contract that required "mutual written agreement with signature" to change the reimbursement methodology.
Numerous inquiries were made to the insurance company to resolve the issue, and the insurance company was nonresponsive, Kehayes says. The ASC sought assistance from the Office of the Insurance Commissioner (OIC). The OIC intervened, and the payer had to make restitution in 30 days because it was a clear violation of contract language, she says.
Keep in mind that if you cash checks from the payer under a new methodology, the payer may claim that you’ve given implied consent, Kehayes warns.
With increasing frequency, same-day surgery providers are going into litigation, Christensen says. "They see that we’re not just going to take what they pay," she adds. "We’re going to ask questions."
Thomas J. Pliura, MD, JD, physician and attorney at law in Le Roy, IL, has filed a suit against one payer that he claims downcoded its groupers. He warns that payers often have the highest paid attorneys. "Much of it is to drag out and outlast you," Pliura says.
• Network with other managers.
Be well read and stay informed through your national, state, and especially local outpatient surgery associations, Blom suggests. He is involved with a local network of administrators, which helps him stay informed about changes payers are making.
"You have to be real diligent; be very familiar with the language or terms and what is the best advice," Blom says. "It’s such a complex issue [that] it’s hard for people to get a grip on it."
Because health care providers constantly are being challenged by payers, Kehayes strives to stay updated on every reimbursement methodology. Because changes typically are driven by changes in the federal government, keep abreast of what is happening at the state and federal level with policy and reimbursement, she advises. "If not, you may not have any idea what’s going on," Kehayes warns.
Source
For more information, contact:
- Lolita M. Jones, RHIA, CCS, Principal, Lolita M. Jones Consulting Services, 1921 Taylor Ave., Fort Washington, MD 20744. Phone: (301) 292-8027. Fax: (301) 292-8244. E-mail: [email protected].
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