Practice Management Alert

Question: Our practice has many managed care contracts, and I do the payment posting. How can I tell whether the amount the HMO is paying is the right amount according to our contract?

California Subscriber

Answer: Your different fee schedules should be loaded into your computer system so you can look at the payment on the explanation of benefits and compare it to your schedule. If your system does not have this ability, consider creating a spreadsheet or a matrix that lists the fee each plan pays for each CPT code you use. For example, your spreadsheet might contain the name of the payers on the left and the list of your CPT codes across the top so you can record the payment for each payer. Then, as you're posting payment, you can check if it is correct.

Some practices simply assume that whatever the plan pays is the correct amount. But payers make mistakes and have been known to use the wrong fee schedule.

Practices often have trouble getting up-to-date fee schedules from payers. Usually, the practice gets a complete schedule when it signs its first contract with the payer, and then never receives an update. Determine your most common procedures by CPT code and ask the payer in writing what the payment is for them. If you limit your request to 10 or 20 top CPT codes, rather than the entire fee schedule, you're more likely to get the information.