Orthopedic Coding Alert

When you-re thinking about signing up to participate with a new payer, you-ve got lots of logistics to work out. If you don't sign the best contract for your practice, you can open the door to an unhappy and unproductive partnership.

Simplify the payer decision and contract negotiation process with this comprehensive questionnaire provided by R. Todd Welter, MSM, CPC, founder and president of R.T. Welter and Associates Inc. (http://www.rtwelter.com) in Wheat Ridge, Colo.

- What is the fee schedule?

- Can the fee schedule be reproduced?

- On which relative value units is the fee schedule based? Which year?

- How are changes to the fee schedule governed?

- How are codes that are not recorded in the fee schedule reimbursed?

- How are physician surgical assists reimbursed? Nonphysician surgical assists?

- Can payment for services be denied as not medically necessary?

- What is the allowable reimbursement for our most common procedures?

Procedure 1

Procedure 2

Procedure 3

Procedure 4

Procedure 5

- Which of the following is included on their identification card: type of insurance (HMO/PPO), copay amount, coinsurance requirements, preadmission requirements, appropriate telephone numbers?

- Which billing form can you use? What will it cost to comply with the required form?

- Are procedural changes and reimbursement rates-preceded by a 30-day written notice?

- What is the recourse if the changes are not acceptable?

- Does the insurer have requirements for the timely filing of claims? Is there a settlement date after which all claims are final?

- Is a period specified for the prompt payment of claims?

- Is the insurance company responsible for informing the patient about covered and noncovered services?

- Must the physician accept all patients referred from the plan?

- What are the provisions for reimbursement of nonparticipating, "on-call" physicians?

- Who is responsible for paying physician claims?

- What are the conditions for accessing of medical records?

- What are the prompt-payment provisions?

- How are coordination-of-benefit claims handled?

- How large a market share (number of patients) does the plan have in your community?

- What is the growth potential?

- What is the company's financial state?

- Are the provisions for the Term and Termination acceptable for your practice?

- Contract period for one year?

- Non-automatic renewal?

- 60- or 90-day termination clause? Is there a tail?

- Obligations after termination?

- What are the cost-containment features (preadmission certification, referral authorizations, ambulatory procedure certification, second surgical opinion, concurrent review, retrospective review)? Are they acceptable?

- Are there sanctions if the cost-containment requirements are not followed? If so, what are they? Are they acceptable?

- What are your obligations, if any, if the plan becomes insolvent?

- What are the requirements, if any, for professional coverage?

- What provisions are there to amend the contract?

- What is the grievance procedure to resolve disputes when they arise?