Primary Care Coding Alert

Hint: it starts by understanding each side’s struggles.

Traditionally, the relationship between the healthcare provider and the payer is an adversarial one. The general paradigm is that the practitioner wants the best possible patient care without passing the payment hassle onto the patient, and the payer is only concerned with minimizing costs and reimbursements. The reality is that both sides rely on the other for successful patient outcomes.

Communication and collaboration are required to successfully build the payer-provider relationship. In her recent webinar, Stephanie M Sjogren, COC, CPC, CDEO, CPMA, CPC-I. director of medical coding and provider reimbursement on the payment integrity team for ConnectiCare in Farmington, CT, goes into detail about ways you can improve your payer-provider relationship.

Note: Sjogren’s experience extends to both sides of this relationship. Prior to working on the payer side, she performed medical record audits and provider education at a women’s healthcare group.

Recognize The Challenges on Both Sides of the Aisle

Both the provider and the payer face challenges that make it difficult to have compassion for the other side. Understanding these challenges is the first step toward building a better relationship.

Provider challenges: Even though providers’ top priority is excellent patient care, they also understandably want to get paid. Yet, it’s becoming increasingly difficult for providers to not just get paid, but get paid correctly or on time. Also, guidelines, financial rules, and payer reimbursement practices keep changing, which is hard to keep up with. “Navigating the complex system of public regulations and private business decisions places primary care physicians in a situation that is increasingly burdensome, overwhelming, and a significant source of physician burnout,” notes Kent Moore, Senior Manager, Payment Strategies, at the American Academy of Family Physicians. “As a result of this system, practices experience increasing operating costs, and physicians have less time for meaningful patient interactions,” adds Moore.

According to Sjogren, payers may resort to claim denials and slow processing to control reimbursement. “Providers can easily lose revenue because they don’t have the time, personnel, or expertise to adequately follow up on the missing documentation or appeal claims, especially if you’re a small office,” said Sjogren.

Payer challenges: “Improper spending is an enormous problem in healthcare,” explained Sjogren. It’s so big that insurers are forced to respond strategically to avoid serious financial losses. Remember that when insurers experience huge losses, health care premiums might have to rise, which means a potentially greater financial burden for patients.

Data from the Centers for Medicare & Medicaid Services (CMS) and National Health Care Anti-Fraud Association says that Americans spent more than $4 trillion on healthcare in 2020. The staggering part of this figure is actually not the total, but rather it’s the estimated $1.2 trillion attributed to waste or abuse that represents unnecessary charges. “That’s about 25 percent of the services in which a payer pays for something that shouldn’t be paid or shouldn’t have been performed,” said Sjogren.

Often, these incorrect payments trace back to incorrect coding.

Understand the Payer Contracts… And Ask Questions if You Don’t

Understanding the payer contracts is vital if you have the opportunity to negotiate any terms and want to do so. The contract outlines the payment rates for services, and without full understanding, it’s hard to manage financial expectations. During the contracting process, request specific CPT^®, revenue, and HCPCS Level II codes when appropriate. “Don’t be afraid to advocate for non-standard language,” said Sjogren.

If there is language in the contract you don’t understand, simply ask about it. After all, failure to comply with the terms of the agreement could result in penalties or even the loss of the contract. In terms of patient care, the contract dictates limitations, such as when pre-authorizations are required and so on. If any of these items are unclear, ask the payer to clarify and provide examples.

Request a solid resolution process: A payer contract should clearly outline a dispute resolution process. “If any of these processes are not within normal guidelines or out of reach for your practice, you will need to address them within the contracting process,” said Sjogren.

Watch new claims carefully: When a new contract takes effect, make sure the payer is holding up their end of things. If you notice patterns, take a sample and audit a few claims that were changed. Look closely at calculations and payment rates to make sure they’re reimbursing you correctly.

Use Software To Meet on Common Ground

When you and the payer share easy-to-understand and a customizable payment processing system or provider portal, you’re already leagues ahead. “Payers and providers that can communicate well within a model based on software offers the best for both parties and simplifies collaboration between them, despite the complex environment,” explained Sjogren.

Electronic payment systems receive payments weeks faster than checks, which accelerates every step of the process afterward. When this process runs like a well-oiled machine, it can reduce labor costs while improving accuracy and productivity. Of course, maintaining up-to-date technologies and automating as much as possible is helpful.

Online utilization management (UM): Payers use UM to review and approve or deny coverage. Providers use it to submit requests for prior authorization and to understand what services payers are likely to cover for their patients. Many physicians see traditional UM as cumbersome, but a useful UM process is one that combats administrative waste that currently exists in payer/provider relations. A focus on strengthening and streamlining cooperation, rather than competition between the involved parties, is essential for reducing discrepancies between the insurance agencies and healthcare providers.

Realize the Real Goal is Patient Satisfaction and Quality Care

Overall, a smooth, communicative, and respectful relationship between the payer and the provider inevitably means a better patient experience. The patient wants the quality healthcare they need, and they want it to be affordable. The best way to make sure all those boxes are checked in a timely, comprehensive manner, is solid communication. “We want to make sure when we’re talking, that it’s collaborative and we’re saying everything we need to say as to why we need these services. Where that becomes important is in our coding, and our relationships,” said Sjogren.