Pulmonology Coding Alert

Healthy skepticism is a good thing where contracts are concerned.

The bigger and shrewder the payers become, the savvier you need to be in payer contact negotiations. Are you making the all-too-common mistakes as you grapple with a payer during a negotiation? Such mistakes will hamstring your profits once you’re locked into a contract.

Mistake #1. Rushing: The negotiation process can take up to a year. Set a “you need us” timeline so that you don’t feel bullied by the payer’s negotiation tactics. You also need time for the physicians, practice manager, billers, and coders in your practice to review the contract against their areas of expertise.

Tip: To be sure you are thinking clearly about whether the contract will benefit your practice’s profits. Do a SWOT analysis: Using the SWOT grid, map out the strengths, weaknesses, opportunities, and threats involved with your business relationship with that payer.

Mistake #2. Accepting a boilerplate contract. “A standard or boilerplate contract is usually one sided, and it favors the insurance company,” warns practice management consultant Steve Verno. Experts agree that you should always bargain for specific points that benefit your practice.

Mistake #3. Settling for “reasonable” as a deadline for claims submissions, payments and appeals. Verno has seen payer contracts that say they will pay claims in a “reasonable” time frame. You can bet you and your payer will disagree what “reasonable” is unless you spell out each time frame in business days.

Mistake #4. Accepting a generic fee schedule attachment. Make sure the payer’s fee schedule contains reimbursement amounts for the codes your eye care practice reports most often.

Warning: Some payers may try to get by with an abridged schedule containing, say, the 10 most commonly billed codes for your specialty. Don’t settle for that nonsense. Ask for the complete schedule.

Mistake #5. Evaluating the payer’s proposed reimbursement amounts in isolation. Make sure your practice manager or biller keeps a grid listing the reimbursement amounts each insurer pays for your most commonly billed codes.

Mistake #6. Focus solely on reimbursement rates: Be sure to check the payer’s policies on modifier use, multiple surgery adjustments, bundling, and other policies that will affect pay up.

Mistake #7. Overlooking pre-authorization and pre-certification requirements. The contract should spell out pre-auths. If the payer says they are “in the provider manual,” make sure you check the manual before signing.