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12.6.21
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The Trouble With Payer Policies

Megan Johnson

Payer policies are used to support coverage decisions and explain reimbursement for health care services to patients who are covered by a specific health plan. These policies outline whether providers are in-network versus out-of-network as well as how much is covered by insurance for things like office visits, surgical procedures, prescriptions, etc. Some payer names you may be familiar with are Medicare, Medicaid, UnitedHealth Group, Anthem, and Blue Cross Blue Shield.

THE CHALLENGE WITH PAYERS

When navigating from one payer to the next, it’s important to know where the pain points are for your practice. I mean, let’s be honest, payers don’t make it easy for us. One of many challenges practices and physicians face with payers is rule inconsistency. Payers aren’t required to adhere to a single set of guidelines, allowing them each to create their own processes and policies. Another challenge practices face is that payers don’t even often adhere to their own rules when it comes to claim processing. For example, a payer that’s behind on processing may say that they didn’t receive the claim even though your practice is set up to submit claims electronically. Or a claim may be denied without the payer providing any explanation of what is needed to process the claim.

MONITOR YOUR PAYERS

So how do practices keep up with the changes without the headache? In a world filled with technology, take advantage of it! You can “like, subscribe to, or follow” payers in your region. Sign up to receive policy change notifications, newsletters, and bulletins through a payer’s website. You can also set a regular schedule to review payer websites. Focus on those pain point areas you’ve identified earlier. Were there changes in the process for authorizations, reimbursements, or coding? It’s important to prioritize knowing your payers. Review your high-volume payers and geographical regions. Then move on to looking at your practice’s high-volume services and identify what charge codes are being billed the most. Are the policies changing so frequently that they can result in denials?

TRAIN AND EDUCATE YOUR TEAM

It’s important to provide training and ongoing education across the organization as well as determine how payers will be monitored (i.e. splitting them up amongst the team).Payer policy changes can have a lasting impact on your revenue cycle if you are not on top of denial management. Let’s strategize on how your practice can work efficiently and effectively to maneuver through payer obstacles.

  • Scrub charges prior to claim submission: think about utilizing software that is designed to prevent improper coding. If your software allows for it, create edits or prompts that prevent improper coding and allow a claim to be fixed prior to the submission process.
  • Reports: create reports that provide visibility into charges and payers. For example, how many times is a charge code being reported by the payer? Is there over-utilization occurring? Reports can provide valuable insight into how payers are processing your claims.

You shouldn’t have to navigate these challenges alone. At pMD, we lift the administrative burden so you can spend time on what matters most. Our experienced revenue cycle management (RCM) experts integrate so tightly with your practice, it feels like we’re just down the hall. You take care of the patients while we take care of the rest! To learn more about pMD’s billing and RCM services, contact us today.

To find out more about pMD's suite of products, which includes our charge capture and MIPS registry, billing services, telehealth, secure messaging, and care navigation software and services, please contact pMD.

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