Medical Billing: Are You Staying Current with Your Major Payers?

It is critical for a medical practice to have individuals who are experts on your major payers. Your billing staff need payer knowledge for accurate paymen…

It is critical for a medical practice to have individuals who are experts on your major payers.  At your front desk, staff need payer-specific knowledge in order to handle financial clearance, accurate registration, referrals, obtain waiver forms when appropriate, and collect time of service payments.  Your billing staff need payer knowledge for accurate payment posting, AR follow up and denial management.  Are you staying current on your major payers?  In the past, we received paper payer newsletters and maintained three-ring binders with the current version of the provider manual.  Today, all of the payers are utilizing Websites to keep their patients, providers, and employers informed.

Your medical practice must stay current on payer policies and required procedures in order to maximize your revenue performance.  Assign responsibility to a staff member to review all major payers’ websites for new information or new functionality at least once a month.  Ask them to communicate their findings to the billing office manager and distribute the information in summary form to all appropriate staff via email or during a staff meeting.  The staff member will need access to the payer websites which usually requires an application to gain access to the sites.  A supervisor or manager should apply for the access on behalf of each staff member who will need to log in.  Selecting a new staff member for this responsibility is an excellent learning experience and it will give them an early way to contribute across the practice.  Rotating this among staff members every six to nine months will keep everyone engaged in staying current on payer requirements.

In addition to traditional websites, many payers will distribute special alert emails or electronic newsletters on specific topics.  An example of this type of payer communication is the new CMS newsletter.  In October, 2010, CMS released its first quarterly compliance newsletter to address billing errors.  The newsletter, “Medicare Quarterly Provider Compliance Newsletter: Guidance to Address Billing Errors”, identified eight billing errors that affect a diverse group of provider types. CMS explains that the newsletter will describe the issue, the problems that may occur as a result of the issue, the steps CMS has taken to make providers aware of the issue, and the recommendations on what providers need to do to avoid the problem. In addition, the newsletter refers providers to other documents for more detailed information where such documents exist.

 The Medicare Quarterly Newsletter goes on to describe each error and its consequences.  The errors highlighted were identified by a number of sources: the Government Accountability Office, the Department of Health and Human Services Office of the Inspector General, the Medicare Recovery Audit Contractors (RACs) and other program contractors.

This first issue of the Medicare Quarterly Newsletter includes an issue affecting physicians: physician pharmaceutical injectables – incorrect procedure codes and/or number of units billed. The other issues featured in October affect hospitals (inpatient and outpatient) and skilled nursing facilities. When CMS explained its new quarterly newsletter, it said that future editions will focus on current top issues, which may focus on a single provider type or item/service.

If you know you are keeping up with the payers’ websites and other materials, what else can you do to stay current?  What other tools are available to manage all of the payer information?  Practices can develop a payer guide or insurance plan summary document that can be provided to each of their practice sites and to their billing office.  A payer guide includes an overview of each payer’s requirements with specific information such as need for referrals, copayment levels, authorized lab and radiology sites, claim filing deadlines, etc.  It also includes a picture of the insurance card (front and back).  Practices will place this information on a Website or local area network so it is easily accessible to staff throughout the practice and at all locations.

You can download a sample payer guide now for your reference.

In order to evaluate whether your practice is staying current on payer policies, review your monthly denial reasons.  Certain denials are directly related to whether staff is knowledgeable about your payer’s requirements.  Here are some examples:

1. Wrong payer:  Appointment staff members who are registering patients over the phone have the added challenge of not being able to see the patient’s insurance card.  If your payer guide includes a picture of your major payers’ cards, your schedulers will be able to ask the patient specific questions about the card being discussed.  This will reduce your denials.

2. No referral or pre-authorization:  Front end staff have responsibilities for ensuring that patients are only seen if the required referral or pre-authorization has been obtained.  In order to manage referrals well, the staff need to know when a referral or pre-authorization is required.  For any one specialty, the list isn’t that long but you need that reference list.  In recent years, payers have reduced the instances in which referrals are required.  Make sure you are not following old rules and creating unnecessary work.

3. Claim past filing deadline:  Each payer has a required timeline in which original claims and claim appeals must be received.  Those should be included in your payer guide and followed closely.

In summary, staying current on payer requirements and policies is critical to your revenue cycle performance starting from appointment scheduling all the way through getting paid!  Ensuring that you read all payer communications and when necessary, implement changes in your practice to stay in compliant is an essential part of managing your payer contracts.  Providing easily accessible payer information to your practice will be the tool for improvement.  Monitoring your denial reasons monthly will ensure that you are in fact staying current with your major payers.