Knowing Your Payer Contracts Isn’t That Difficult – Or Is It?

Ensuring maximum reimbursement is always at the top of a healthcare provider’s mind. But we find too often that many providers and administrators are leaving money on the table with inefficient and infrequent #payercontractmanagement.

While working with healthcare groups across the country, we have seen payers reduce their fee schedules by 5% to 12% due to lack of attention, this is devastating to your practice.

Practices that don’t track their payer contract rates are reimbursed on average 4 percent less.

It actually isn’t difficult to pay attention to contracts, organize key information in a readily accessible way and know what you are (or should be) getting paid. Yet so many practices don’t do these things – or they do them with insufficient attention and resources. Why?

Truthfully, we are not writing this article to answer the above “why”. We do however want to provide you with some insight, processes and options. Here we go.

The Importance of an Accurate Payer Matrix

A payer matrix is essentially a table that lists key data for each payer, including;

• Payer Name
• Type of Contract (Direct, IPA, PHO, Individual, Group, etc.)
• Original Effective Date
• Term
• Termination Notice (Days)
• Reimbursement Methodology and Rates
• Provider Relations Representative Contact Info

Without that information complete and readily available, it can be cumbersome to figure out who to contact in the payer organization, and it can be nearly impossible to determine whether your terms are fair and you’re getting paid what you should.

Analysis and Action

Beyond the up-to-date payer matrix, healthcare organizations also must pay attention to how well payments match their contract terms. Many billing systems have built-in “expected payment” reporting tools, designed to flag when reimbursements are either above or below expectations. Yet, all too many business managers are unaware that they have these tools, or simply do not use them. Either way, if you aren’t seeing this kind of reporting on at least a quarterly basis, your organization probably isn’t monitoring and recognizing issues that could become serious problems.

How to Get the Most from Your Payer Contracts Using Your CodeToolz Contract Analyzer

Fortunately, longstanding patterns of poor attention to contracts can be broken. Our Contract Analyzer is designed to track and manage your payer contracts, analyze fee schedules, manage options for payer negotiations and increase the bottom line.

Given the financial, operational, and legal implications of managed care contracts, automating contract terms and managing the requirements of a multitude of contracts has moved beyond the capabilities of manual processes.

CodeToolz Contract Analyzer Features

Organize your contracts and fee schedules into a matrix so that you can easily see contact information, your reimbursements and key provisions such as termination requirements, and how much time you have to respond to proposed amendments (which may indicate lower fees).

Reminders for renegotiation are provided, giving you enough time to handle them appropriately. So, say a contract is set to expire on December 31, and there is a 90-day termination provision. That means you should start the renegotiation process in July, so that you can have new terms set by mid-August – before the 90-day termination deadline.

Examine your payment vouchers and audit your Explanation of Benefits (EOB) documents routinely. Verify if you’re getting paid correctly by looking at your top payers for payment inconsistencies and keep in mind that if you are not being paid fairly or accurately, the onus is on you to alert the payer and help ensure a correction.

Recognize when reimbursement is tied to the Medicare schedule. Analyze the best Medicare schedule for your practice and common procedures. Then negotiate with your payers to base reimbursements on the most favorable schedule – even it if is not the most commonly used one.

Verify termination deadlines. Contract termination can seem like a drastic last resort when a contract is unfavorable. Sometimes, however, it must be done, particularly if a payer refuses to communicate with you. Most contracts include a clause requiring a termination notice of at least 90 days. But if you need any paperwork or information from the payer, they may not release it until it’s too late.

Features Summary

• Organize, analyze and maximize your payer contracts and fee schedules in one simple place.
• Determine what various reimbursement rates will do to your bottom line, in aggregate and by #cptcodes code for all your payers.
• Compare your #payerreimbursements on an ongoing basis; test the adequacy of your charges, test payer offers, your counteroffers and much more.

Our roots in payer contracting run deep, making CodeToolz one of the most effective payer contracting and reimbursement firms in the country.

Conclusion

Payer contracts are significantly complex and require considerable maintenance to ensure your reimbursement adheres to contract terms. Regardless of whether your organization chooses to maintain its contract system and manage underpayments internally or in partnership with a vendor, there are critical focus areas and capabilities that can significantly affect success.

Revenue capture and accurate reimbursement have never been more important. Consider the significance of contract compliance and revenue integrity as you build a strategy for your organization’s financially sustainable future. #payercontractmanagement #cptcodes #payerreimbursements

Let the experts at CodeToolz take your contracting efforts from burden to competitive advantage. The bottom line is that in negotiations, knowledge is power and planning is essential. Contact Us Today! (512) 787-1852