Revenue Leaks and Payer Issues
Depending on your practice, office managers or the billing manager should be reviewing contracts consistently and verifying that payers are submitting payments for the contracted allowable. Questions to ask include: Does your practice know what services should be paid? Are there services like laboratory tests which are not payable to your office? Does a particular patient need to go through a specialty pharmacy for treatment medications?
Practices also need to know their contracted allowable for each service, and at least the larger payers should have their allowable amounts loaded into the practice billing program. This will make it easier to monitor payments that differ from the contract price. Software programs can be set up to flag electronic payments as they post so that staff can check to see payments are accurate.
The payer contract details play an important role in plugging revenue leaks. Practices needs to understand:
• The appeals rights and process with each individual payer
• Who determines medical necessity for the patient
• The state regulations by payer for late payments
• The process for audits and reviews, including the limitations on retrospective audits. This last detail is very important to be included in the contract.
Recently, some payers have issued a “credit card” to providers as payment for their services, but could include a transaction fee as high as 5% per transaction, resulting in a decrease off the negotiated payment rate. The AMA released an FAQ on the payer cards, but recommends that practices review payer contracts to see if they are required to accept the cards as a method of payment.