Improving payer contract management by analyzing terms and assessing payer performance can maximize revenue for healthcare providers.

Payer contracts contain fee schedules and reimbursement requirements, as well as the conditions payers must meet for timely reimbursement.

Ensuring correct reimbursement in a timely manner is always at the top of a healthcare provider’s mind. But many provider organizations could be leaving money on the table with inefficient and infrequent payer contract management.

Therefore, payer contract management is key to ensuring payers reimburse practices and hospitals the correct amount each time a claim is submitted.

Many provider organizations have failed to implement comprehensive payer contract management practices because of the complexity associated with negotiating and managing multiple contracts.

Payer contracting, whether it is commercial payers or government payers, and the credentialing process is complicated, cumbersome, lengthy and time-consuming,

It’s very hard for a medical practice to keep up without getting discouraged by the process because it is lengthy and complicated.

Provider organizations can overcome these challenges and maximize their revenue by understanding the basics of payer contracts, diving deeper into contract language, creating a central space for contracts, and preparing for negotiations.

1. UNDERSTANDING THE BASICS OF PAYER CONTRACTS

While payer contracts are legal documents, providers and practice or hospital administrators do not need a legal degree to understand the terms of each contract. Payer contracts may seem complicated, but ensuring providers and administrators understand the fine print can help organizations capture all charges and prevent claim denials.

It’s incredibly important for practice administrators and physicians to understand their contracts and know what they are getting paid.

Providers usually know the payment rates for commonly billed services at their organizations. However, payer contracts contain a lot more information than just the rates for these services. The fine print can easily create revenue cycle challenges for provider organizations.

On top of the rates for commonly billed services, providers and administrators should also be aware of the following core elements of any payer contract:

• The number of days a provider has to submit a claim after a service or visit
• The number of days a payer has to reimburse the provider for covered services
• Scope and list of services covered by the payer
• Reimbursement rates for all covered services
• Claim denial dispute procedures
• Term of contract
• Notice periods for renegotiation and termination

Understanding all of these terms is key to not just receiving payments, but maximizing reimbursement. For example, knowing the codes for all covered services ensures that claims are complete and providers get paid for every covered service they perform, even if it is not a commonly billed one.

Digging into all the provisions of a payer contract also helps provider organizations prevent and fight claim denials because they understand all the requirements for reimbursement on both their side and the payer’s side.

2. CONSIDERING LANGUAGE WHILE CONTRACTING

Once practice or hospital administrators understand the basics of payer contracts, they can start to dive deeper into contract language. Understanding common clauses and requirements included in the majority of contracts will improve payer contract management and help provider organizations protect their revenue.

3. UNILATERAL AMENDMENTS

Contract language pertaining to unilateral amendments can be particularly important. These clauses state that payers can change reimbursement rates, requirements, network participation, and even contract language whenever they please.

Most payer contracts say that the payer can amend the contract at any time. In the worst case, they say that no approval is required from the provider at all. In the best case, they’ll say, ‘We are amending this contract and you have 30 days to object to the amendment in writing or it automatically goes into effect.

With revenue at risk under unilateral amendment language, provider organizations should not accept contracts from payers that include this clause.

Thirty days is such an unattainable period of time for a practice that is trying to keep up with all of this.  At the very least, ask for 60 to 90 days. But ideally, organizations should not allow unilateral amendment language in the contract at all.

4. REIMBURSEMENT POLICIES

Payers typically have reimbursement requirements that are not explicitly detailed in individual contracts. But provider organizations must still abide by these policies or face claim denials.

While payer contracts contain language pointing to these reimbursement policies, the clauses also typically state that the payer can change these policies whenever they choose.

That’s a big catch-all that can trap providers because it ties reimbursement to policies not specified in the contract.

However, provider organizations may not be able to avoid the clause.

In most cases, they can’t really take out language that says they will abide by reimbursement policies because these clauses often include mechanisms such as medical necessity guidelines or pre-authorization protocols.

They just need to be aware of the language pertaining to reimbursement policies and how broad it is.

5. NETWORK REQUIREMENTS

Payer contracts also detail the networks in which provider organizations can participate, as well as the credentialing requirements providers must meet to join a network. Ensuring a provider organization is in the appropriate network is key to revenue generation because plan networks guide members to the organization.

However, contract language regarding network changes can lower revenue for provider organizations. Payers can redesign networks to include different physician positions, such as specific specialists. Practices or hospitals lacking those positions can be eliminated from the network.

Value-based care is producing different networks for different products. There’s always language in contracts that pertains to credentialing criteria that you have to meet in order to be added to the network. But oftentimes a contract will also have language that states that the payer can pick and choose which positions can participate in which networks.

Ideally, a payer contract should never include language that allows payers to select a provider organization’s network.

6. IMPLEMENTING A PAYER CONTRACT MANAGEMENT SYSTEM

Adding to the complexity of payer contract management is the fact that provider organizations work with multiple payers at once.

Once providers have all their contracts available, they should implement an automated system that stores and tracks the documents. Merely maintaining a spreadsheet of contracts will not result in comprehensive, streamlined contract management.

The ability to view all contracts can also help provider organizations standardize contracts and pull out common clauses that their staff should be aware of. Based on all contracts at the organization, administrators can create a standard version of a payer contract and use that contract when negotiating with payers.

PREPARING FOR PAYER CONTRACT NEGOTIATIONS

With the ability to understand payer contracts comes the ability to renegotiate terms that favor the provider organization. Payers do not hold all cards when it comes to determining reimbursement rates. Provider organizations can use contract and performance data to convince payers to give the hospital or practice a more favorable rate.

To start this process, provider organizations should start to analyze fee schedules and payment processes to determine the performance of each payer. Providers should focus on the rates for the organization’s most commonly billed services.

Developing data-driven, evidence-based responses to these potential questions or push backs will put providers in an ideal place to negotiate.

Providers and practice or hospital administrators may feel overwhelmed when it comes to managing the nuances of payer contracts, but breaking down the issue can help to clarify these important relationships.

Follow the link to learn more about Payer Contract Negotiation http://localhost/main-site-update/payer-contract-negotiation/

However, depending on the level of sophistication of EHR systems, this may not be as easy as it sounds. The switch to value-based analytics reporting increases the challenges and potential headaches.

Here are some reporting suggestions that may help your practice save time, money and aggravation while improving your rates of payer reimbursement:

Financial Reports: Information Every Medical Practice Should Acquire

⇒  Denied Claims Report

As any physician knows too well, denied claims cost money in lost revenues as well as staff time spent finding the cause of denials, followed by re-billing. Be sure to pay attention to each payer’s EOB to determine not only the reasons but their codes and explanations line up with how you bill claims.

According to a recent survey from the following are trends in denied claims:

• Demographic, as well as technical denials, have risen over 100 percent since the last survey, resulting in increased write-offs.
• The success rate of appeals on denials was only between 50-56 percent.
• Commercial payer denials had risen by over 26 percent of total denied claims.

Having a good revenue analytics program can help practices and other organizations detect denial patterns as well as the amount of recoverable revenue.

A denial analysis report can also be broken down further into two separate denial categories based on:

• The payers who were the source of most denied claims
• Top CPT codes over which claims were denied

⇒  Profit and Loss statement (P&L)

This report shows how profitable practice is by tracking income (revenues) and expenses. It can help identify key performance indicators (covered further below) including total patient encounters, procedures, charges as well as any collected monies. Any drop in revenue (collections) is a warning before taking action.

An example could be a decrease in the prior month’s billing would likely result in a drop in this month’s collections.

⇒  Key Performance / Provider Productivity Indicators

Your provider productivity and performance report should show how each physician is contributing to how to increase revenue-producing with quality measures while keeping costs under control, making it one of the practice’s most important reports.

In addition, having efficient systems software now enables you to do in a matter of minutes what used to take days: track total charges, collections, procedures, encounters, A/R outstanding and adjustments.

⇒  Accounts Receivable (AR) Aging

Whether fee-for-service or value-based, this report is essential to determine which claims are outstanding and why. As with denials, unpaid claims are a drain on revenue, so use your analytics to track any claims over a month old. If still unpaid after 45 days, you need to check to see whether it was paid and possibly posted to the wrong account or whether it was denied or still unpaid.

⇒  Clearinghouse Rejections and Benchmark Metrics

Early in the switch to ICD-10, a number of payers added set-specific coding in front-end translations, resulting in entire groups of claims rejected, usually at the claim-acknowledgment stage with a 999 designation. Use analytics to determine which denied claims are due to erroneously using both ICD-9 and ICD-10 coding as well as codes with wrong qualifiers.

⇒   Value-based Reporting

This may be one of the most important considerations as you run reports:  moving into value-based reimbursement, the practice’s quality measures should have been captured for the Merit-based Incentive Payment System (MIPS) along with others. Using clinical registries and other sources, providers should be able to compare physician and practice-quality scores against their peers. Quality measures can also reveal areas needing improvement along with gaps in care.

⇒   Removing Obstacles to Reporting

Issues with interoperability between providers’ systems as well as the quality and quantity of data collected can all make sharing data, analyzing and reporting a logistical nightmare.  The result could be missing key metrics and critical financial information which can lead to bad business decisions that could cost you your practice.

We can help eliminate risks of above mentioned miscoded claims as well as identify other areas where you may losing revenue and to track and identify unpaid claims so your practice is reimbursed in a timely manner.

Contact us or Schedule a free demo http://localhost/main-site-update/live-demo/

In recent times, there have been a number of changes in the reimbursement models and payment methods for independent medical practices. This has meant physicians in private practice are facing new and different challenges every day. The financial stability of small medical practices is in jeopardy due to stiff competition and changes in insurance coverage.

To mitigate the risk of decreased revenue, perhaps the most important thing an independent medical practice can do is to ensure efficiency in Revenue cycle management (RCM) and integration with the Electronic health record (EHR) system.

If healthcare providers in independent practice do not keep up with changing reimbursement policies, rules, and regulations, there’s a good chance they will simply be unable to compete in this dynamic healthcare environment.

The ability and willingness to adapt to new regulations and policies are critical to the success of any medical practice. It is possible to scale up your practice and maintain or increase revenue without completely overhauling your revenue cycle management.

Here are four ways to survive reimbursement changes and grow your independent medical practice:

1. Embrace Value based care:

The fee-for-service payment model is giving way to value-based care. Physicians will no longer be reimbursed based on the number of patient encounters or tests requested. Instead, providers will be scored according to the merit-based incentive payment system (MIPS) where reimbursement is linked to meeting certain standards of care.

Another consequence of the push towards value-based care is an increasing number of patients with health plans that have high deductibles. These low premium plans are patient-friendly, but independent medical practices must adjust their RCM strategies to collect payment from patients who are responsible for a greater proportion of initial costs. Of course, independent providers must continue to provide the highest quality of care while doing this to be eligible for the reimbursement bonuses under the new payment models.

To learn more about on Value based care, Please follow the link http://localhost/main-site-update/value-based-care-best-option-lowering-healthcare-costs/

2. Focus on Financial Performance

To remain financially stable in a competitive market, smaller independent practices must focus on every aspect of financial performance.

A commitment towards best practices in billing, collections, and cash flow is necessary for a multipronged approach to surviving reimbursement changes.

Medical practices should measure a number of metrics and compare them to industry averages:

• Denial rate.
• Collections at the time of patient encounters.
• Accounts receivable past due more than 120 days.
• Net collection rate.
• Cash collection rate.
• Outstanding accounts receivable.

3. Establish Connectivity

For independent practices to flourish in the current healthcare scenario, it is critical to establish connectivity and integration with other providers and healthcare systems. Rather than looking at integration as a one time investment in technology, independent medical practices should develop integration strategies that lead to ongoing improvement in the quality of care and a reduction in costs.

An EHR that offers seamless care coordination and exchange of data can make the integration process less taxing for independent clinics. For most practices, the budget is a limiting factor in implementing integrated care.

4. Practice Risk-Based Care

To most physicians, a risk-based environment is an alien environment. However, to thrive in the face of changing reimbursement policies, it’s a good idea to embrace risk and practice risk-based contracting. The trick is to know your patients well, identify patients who are high-risk, communicate value-based care to patients, and make appropriate referrals to specialists for the transition of care.

Business analytics plays a key role in identifying high-risk patients and is strategically imperative to survive reimbursement changes.

Independent medical practices need to maximise efficiency and financial performance, and be prepared to handle new methods of reimbursement. Typical revenue cycle management solutions are not sufficient to meet the demands of practising in a new, value-based health care system. That’s because new models of reimbursement require that revenue cycle systems track and submit cost and quality data, as well as receive and appropriately distribute compensation based on practice performance.

What is Value based Care?

Value based care is a clinical inefficiency and duplication of services, and to make it easier for people to get the care they need. This form of reimbursement has emerged as an alternative and potential replacement for fee-for-service reimbursement which pays providers retrospectively for services delivered based on bill charges or annual fee schedules. Overall wellness, quality of care, and preventive screenings all are key to bringing about better outcomes.

What does that mean for you?

Value-based care is designed around patients. Medical care teams zero in on individual needs, whether preventive, chronic or acute. It coordinates your care, and technology that connects you and your providers with information to help you get the right care across the health care system.

As many explore alternative solutions, one solution that has been embraced by some is value-based care delivery models. There are four models in action.

1. Accountable care organisation (ACO): An Accountable Care Organisation (ACO) is a group of healthcare providers who agree to be jointly accountable for both the quality and the cost of the healthcare of a defined patient population. ACOs are alliances of doctors, hospitals and other health care providers that deliver and coordinate care for their patients. Doctors and health systems that successfully manage the health of the entire population reap the rewards. However, if they do not improve quality and control the cost of care, they may lose money. For you, that means a team of providers is incensed to work together to keep you healthy.The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.

To find out more about on Value based care and how WWS may assist you contact us +1(302) 613-1356 or http://localhost/main-site-update/medicaid-accountable-care-organizations/

3.  Patient-centred medical home (PCMH):A patient-centred medical home (PCMH) is a model of care that aims to transform the delivery of comprehensive primary care to children, adolescents, and adults.Partnering with patients and their families requires understanding and respecting each patient’s unique needs, culture, values, and preferences.Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner. 
4. Pay for performance (P4P): It is a payment model that offers financial incentives to physicians, hospitals, medical groups, and other healthcare providers for meeting certain performance measures. Doctors, hospitals and health plans together develop and agree to a set of quality and efficiency measures. P4P programs are supported by insurance providers, Medicaid or Medicare. P4P creates a system that rewards healthcare for efficiency and penalises for increased costs, poor patient outcomes and medical errors.
5. Bundled payments: In a bundle payment arrangements are designed to pay multiple providers for coordinating the total amount of services required for a single, pre-defined episode of care such as hip or knee replacement. These payment models promote a coordinated, efficient and cost-conscious effort for specific treatments or conditions. Bundled payment rates are determined based on the costs expected for a particular treatment, as well as costs for any preventable complications that may arise.

“Value-based care models are highly attractive to healthcare providers. This module is designed to help your practice make the shift towards this model so that your patients and team can reap the benefits of this outcomes-focused approach that incentives high quality, patient-focused care and reduces overall health care costs.”