Mastering Healthcare Contract Payments for Providers
Navigating the complexities of obtaining healthcare insurance contract payments can be daunting for providers. From deciphering convoluted terms to managing denied claims, the process is fraught with challenges. This blog post aims to provide healthcare revenue cycle and financial leaders, and medical billing professionals with actionable strategies to maximize contract payments. We'll explore the payment process, common hurdles, best practices, and the latest technological innovations. By the end, you'll have a comprehensive understanding of how to ensure you're being paid correctly and how to manage your payer contracts effectively.
The Basics of Healthcare Insurance Payer Contracting
In the world of healthcare accounting, it's crucial to have a clear grasp on revenue expectations projections. By effectively monitoring collections, making contractual adjustments, and understanding net revenue collection rates, you move one step closer to answering the question: "Am I really earning what I should be?" Healthcare insurance contracting involves agreements between providers and insurers that define the terms and conditions for service payments. Key terms include "allowable amount," which is the maximum reimbursement the insurer will provide, and "fee schedule," which serves as a list of services with corresponding payment rates.
The Contract Negotiation Phase
During the negotiation phase, providers and insurers agree on the rates and terms. This stage is critical as it sets the foundation for future payments. Ensure you understand the contract language to avoid surprises later. Examples of "surprises" could include a lesser-of clause, downcoding clause, policy amendment timeline, etc.
Monitoring and Compliance
Once the contract is in place, continuous monitoring is essential. Regularly review compliance with the agreed terms to catch discrepancies early and often. Underpayments, denials, and write-offs happen, but they shouldn't overtake your organization.
Common Hurdles in Payment Collection
Denied Claims
Denied claims are a significant hurdle. Common reasons include coding errors, missing information, and eligibility issues. Denials can delay payments and affect cash flow. Recently, Cigna was found to automatically deny claims without any sort of adjudication. With this discouraging information there are many things that you can still do. Enhance your denials remediation strategies through trend discovery with a technology such as Rivet, which allows you to instantly review trends and overarching denial reasons and take immediate action.
Underpayments
Underpayments occur when the insurer pays less than the contracted rate to the provider. This often happens due to errors in claim processing or misinterpretation of the contract terms. Underpaid claims are the silent revenue killer of your organization, but it can be difficult to delve into the can of worms that comes with manually assessing underpaid claims and appealing batches of claims with the same issue. What's worse, you may spend hours of manual labor believing you've been grievously underpaid only to discover from your payer that amendments have been made to the contract without your knowledge; usually because changes were made before you started your current position, but sometimes it is because changes are made and sent via snail mail and they aren't logged digitally for later review. Rivet has a solution that suggests underpayment projects based on trends and helps you to rework them.
Timely Filing Limits
Most contracts stipulate a time frame within which claims must be filed. Missing this window can result in denied claims. Understanding these limits is crucial for timely payment. With Rivet, all your contract terms are loaded for you, so you can easily keep track of timely filing limitations for appeal, initial filing, and more. Rivet even watches out for your negotiation timelines.
Fighting Underpayments and Denials
To combat underpayments, regularly audit your claims and compare them with the contract terms. For denials, implement a robust denial management process to identify root causes and take corrective actions. In Rivet, you can utilize your projects to help you negotiate new contract terms.
Fixing Coding Errors
Coding errors are a common cause of denied claims. Ensure your coding staff is well-trained and up-to-date with the latest coding guidelines. Use coding audit tools to catch errors before claims are submitted. One Rivet customer in family medicine found that one coder was losing their organization thousands of dollars because of persistent coding issues that they found in their underpayments and in their denials. They were able to jump in and educate their coders and now the issue is resolved and they are getting the payment they deserve.
Effective Negotiations
Negotiation skills are vital for securing favorable contract terms. Understand market rates and use data to support your negotiation points. Don't be afraid to renegotiate terms if the initial agreement is not beneficial. Rivet has tools for benchmarking how your contract allowables compare to competitors in your geographic area, price comparison, new price modeling, and monitored payer issues to maximize negotiations so that you can obtain better reimbursement in your future contracts.
Whether you choose Rivet or another vendor, real-time data analytics can provide insights into payment trends, allowing you to make informed decisions. Use these tools to monitor reimbursement and identify areas for improvement.
Conclusion
Mastering healthcare insurance contract payments requires a deep understanding of the payment process, proactive management of common hurdles, and leveraging technology. By implementing the strategies discussed, medical billing professionals, healthcare CEOs, and revenue cycle managers can ensure accurate payments and improve financial health. Take the next step and empower your organization with these insights—start by auditing your current contracts and exploring technology solutions that can streamline your processes.
For those looking to elevate their payment processes further, consider booking a demo with our experts at Rivet. Our team can help you refine your strategies and ensure you're maximizing your contract payments effectively.
Learn more about Rivet: https://www.rivethealth.com/payer-performance
