Medicare Compliance & Reimbursement

Tip: Get a good EHR solution with outstanding reporting and coding facilitation features.

Focusing on clear communication between your practice and payers needs to be a top priority, but it’s not always easy to implement. Read on for some important best practices that can help you get the message across and keep your payment stream flowing.

Communicate and Document

In earlier times, interactions between payers and providers generally took place between the treating physician and the chief medical officer (CMO) of the payer. Now, however, payers are more likely run by executives with financial backgrounds. Therefore, the nature of communication has changed. It is, however, still important for providers to touch base with the payers regarding their problems and clarify all doubts that arise. This communication is generally with the payer’s contract management representative or team.

Some larger physician practices, ASCs and multi-specialty groups as well as most hospitals have internal contract management staff to facilitate this process, says Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS, president of SLG, Inc. Consulting.

Tip: Document all conversations between the provider and the payer. This helps keep track of all communication and gives you something to refer to when needed.

Be Part of a Larger Association

It always helps to be a part of a practice association, especially if you’re part of a smaller provider. This connection allows providers to benefit from economies of scale and the associated negotiating leverage. It also empowers them to hire professional managers or upgrade to better electronic health record (EHR) systems that can be helpful in making a case for reimbursement. A database of patient centered records with the advantage of instant and secured access helps you negotiate with ease. If you can substantiate that you are avoiding overutilization, it may help you negotiate a pre-authorization waiver that can save money and time.

Use Technology Wherever Possible

The never-ending paperwork in the billing industry leads to a great expense and increased administrative burden. Having a good automated system in place with at least these four features helps to reduce the burden to a great extent:

• A system for acquiring medical records in an electronic format for each patient and storing them in central database;

• A system which can retrieve patient demographic information electronically from your hospital’s registration system;

• A system which can electronically submit to Medicare, Medicaid, Blue Cross/Blue Shield, and any other third party capable of receiving electronic claims;

• A system capable of electronic funds transfers with capable third parties to ensure payments are deposited directly into your bank account.

A good EHR solution with outstanding reporting and coding facilitation features helps you submit clean claims and bring down rejection rates. Some payers will have provider portals which allow you to check the claim status and complete other administrative tasks online.

A Good Rapport Goes a Long Way

Strong business relationships depend on consistent professionalism and courtesy. Therefore, good relationships between the payers and the providers pave the way for smooth interactions even in complicated situations. Your facility could end up dealing with the same individuals at payer organizations repeatedly, so developing good rapport can help keep your relationships positive over the long term, making it more likely you’ll get the help you need from them.