Pulmonology Coding Alert

Payers:

Acknowledge the Need for Strong Relationships with Payers

Published on Tue May 07, 2024

Getting glimpses of the payer experience is a good first step.

While providers may not be eager to gussy up their relationships with payers, prioritizing good communication — and even collaboration — is crucial to a solid foundation for a working relationship.

In a 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, Connecticut, offered details about ways to improve the payer-provider relationship.

Sjogren’s insights are well worth understanding, as her 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.

Here’s what she had to say.

Know That Payers Face Challenges, Too

Providers and payers may see each other as adversaries in business, even though they rely on each other. Understanding the specifics of what each side is facing is key.

Provider challenges: Even though providers’ top priority is excellent patient care, they also want to get paid. However, reimbursement — in the correct amount or on time — is increasingly difficult for providers to secure. Guidelines, financial rules, and payer reimbursement practices keep changing, and it can be hard to stay on top of the updates.

“Navigating the complex system of public regulations and private business decisions places … physicians in a situation that is increasingly burdensome, overwhelming, and a significant source of physician burnout,” said 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.

Payers may resort to claim denials and slow processing to control reimbursement, Sjogren said. “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,” she said.

Payer challenges: “Improper spending is an enormous problem in healthcare,” Sjogren said. It’s such a huge issue that insurers are forced to act strategically to avoid serious financial losses. Remember that when insurers experience huge losses, healthcare premiums might 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 not the total; an estimated $1.2 trillion is 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,” Sjogren said.

Often, these incorrect payments can be traced back to incorrect coding.

Be Specific With Payer Policies

Understanding payer contracts is vital, especially 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, you can 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,” Sjogren said.

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 an easy-to-understand, customizable payment processing system or provider portal, you have fewer barriers to effective communication. This “offers the best for both parties and simplifies collaboration between them, despite the complex environment,” Sjogren explained.

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 also 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 combats administrative waste that currently exists in payer/provider relations. Focusing on strengthening and streamlining cooperation is essential for reducing discrepancies between the insurance agencies and healthcare providers.

Aim for Quality Care and Patient Satisfaction

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.

When we’re talking, “We want to make sure … 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,” Sjogren said.

Rachel Dorrell, MA, MS, CPC-A, Development Editor