By Jennifer Foskett, MBA, RHIA, CPC
Payers and providers often seem to be in a battle to prove who the bigger advocate is. It is important we work to bridge the gap between providers and payers to ensure that the care of patients is put first.
As Mackenzie Bean writes in an article from Becker’s Hospital Review, “Collaboration is the key to ensuring a successful payer-provider relationship. However, effective collaboration requires mutual understanding between both parties.”
Revenue cycle professionals in health information (HI) are the advocates for providers, so it is typical for staff involved in the revenue cycle to be defensive when there is discussion about payer behavior. However, much of this defensiveness is due to a lack of education on insurance company policies regarding coverage of services provided to patients.
As a standard, the more costly the care a provider is rendering, the higher likelihood a policy will impact reimbursement. Keep this in mind as you prepare to prevent denials. What payer reimbursement challenges are being faced that are creating pain points within the practice or facility? Does the provider practice or facility have an existing relationship with the payer or provider representative? How often is your organization meeting with the provider rep to address high-dollar issues? Collaborating and nurturing the relationships you have with payers will play a role, and internal collaboration between the organization with contracting, business office, and the HI department could provide valuable insight on how to resolve reimbursement challenges.
Additional tips to facilitate collaboration and reduce the abrasion between providers and payers:
First, gather data across the revenue cycle. Work with the business office to evaluate trends related to denials and refunds, and gather data related to claims processing behaviors for specific payers. Collaborate with the HI department to get information related to DRG validation or coding corrections that result from records requests from the payers. Finalize the data collection with presenting these patterns from the business office and HI to get insight related to underpayments or other reimbursement challenges related to payer and provider contracts.
In another Becker’s Hospital Review article, Brian Andrews and Kurt Anderson write, “From a provider’s perspective, however, when payers don’t remit accurate payments in a timely fashion, providers lose that revenue and experience significant disruptions in their cash flow. If payment inaccuracies or delays are excessive or recur, it can greatly impact a provider’s viability over time.”2
Remember, payers have guidelines related to the value-based payment models. With the implementation of the Affordable Care Act, payers are held to standards related to reimbursement they give to healthcare organizations and providers. These payments must be supported by the documentation to ensure that they are upholding these standards and to adequately share the patient story.
Organize and Meet
Second, after the data is gathered and collaborated internally within the organization, the next step is organizing examples of claims and setting up meetings with the payers. Work with contracting to get in touch with provider reps that the organization already has a relationship with. This will be an opportunity to discuss payer behavior and also updates to payer policies that may be difficult to find and need to be communicated with the provider or facility. This information needs to be easily available for providers and health systems to access. If healthcare organizations are to follow payer policies, this information should be readily available so that they know what policy is being applied to denials and recoupments that are done on a consistent basis. Payers should also be providing updates via a provider newsletter to give direction on where this information is located as well.
Create Policies and Procedures
Lastly, after a few consistent collaborations with payers are completed, and the challenges are addressed, policies and procedures can be put into place to prevent denials and ensure claims are transmitted cleanly within the organization and denials and claim delays are reduced.
Using trends in denials and underpayments as an evaluation of payer behavior is an important and ongoing discussion between the provider/organization and payer relationship. Identifying trends to ensure that issues related to contract negotiation, missed communication of payer policy updates, and having an ongoing dialogue is important to encourage process improvement and collaboration within the payer/provider relationship. Healthcare organizations should be able to categorize errors and denials to prevent reoccurrences. This will challenge each party to maintain accountability and work together resolve and prevent these issues. There should be ongoing discussions to identify these issues.
Table: Example of Errors and Denials Categorized by Department Best Able to Prevent Recurrence
|CO-50||The services are not covered because the insurer does not deem them to be medical necessities.||Registration|
|CO-120||The patient is covered by a managed care plan.||Registration|
|CO-182||The procedure modifier was invalid on the date of service.||Coding|
|CO-138||Appeal procedures were not followed, and time limits were not met.||Billing|
|CO-18||The claim or service is a duplicate.||Billing|
As revenue cycle professionals, it is important for us to bridge the gap and advocate for our providers within our health systems. Health information professionals are uniquely positioned to support the providers and communicate the issues within the practice with the providers. If payers are auditing specific claims, HI professionals can identify trends related and have a discussion on the audit trends. If this is due to a Recovery Audit Contractor (RAC) audit, are you communicating with providers and facility of what trends the Centers for Medicare and Medicaid Services is looking for? Healthcare providers can use information obtained through these audits to identify trends in reimbursement and denials to provide education and ensure timely and compliant reimbursement for healthcare services.
For more information on additional tips toward successful payer-provider collaboration, check out this roundtable from 2019.
Jennifer Foskett (firstname.lastname@example.org) is a health information management professional, local speaker, and the owner of medicalcodingformillennials.com.Leave a comment