Pulmonology Coding Alert

Watch out for auto-renew clauses, slow credentialing for new hires.

Yes, you can stand your ground in a payer contract negotiation if you know the ropes. Here’s what to look out for as you suss out potential payers and review the contract your payer comes up with, says AudioEducator speaker Melody Irvine.

How good is the payer’s online access? Is the payer’s site user-friendly? Does the payer promptly update beneficiary and claim information so that your back office can easily look up insurance verifications?

Is the payer accredited by the NCQA? The National Committee for Quality Assurance is an independent organization that reviews insurance companies to make sure they are financially sound, explains Irvine.

Are clinician responsibilities reasonable? Will the medical record requirements turn you into a documentation drudge? What’s your responsibility for phone calls, hospital visits, or ED visits?

How hard is it to onboard new physicians or NPPs with the plan? Make sure the plan’s credentialing process isn’t so sluggish that you’re stuck waiting around to monetize a new hire’s services.

What are the deadlines for contract renewal? Make sure there’s no evergreen clause that automatically renews the contract, Irvine warns. You want the ability to re-negotiate every year.

Does the contract have a most favored nation clause and if so, are you okay with that? An MFN clause requires you to give that plan the lowest rate you’ve negotiated with any other plan.

Does the contract have a silent PPO clause? If so, you should eliminate it, Irvine says. Silent PPOs have been around for a long time, but they can catch practices unawares, she warns.

What’s the policy for retroactive denials? Prohibit the plan from rescinding money if the claim is more than 120 days old, Irvine suggests.

What are the offset and withholds provisions? These terms give the plan the ability to withhold payments from your practice for a variety of reasons, including incorrect or duplicate payments. Make sure there is a time limit for withholds and that they kick in only after you’ve been given the right to appeal, Irvine recommends.

Does the contract define ‘clean claim’ clearly? Should you add a provision that the insurer add interest to denials of clean claims when the payments come in too slowly?

Eyes Open: Check the payer’s definitions for other revenue-crucial terms like “timely filing” and “medical necessity.” These definitions may be in the policy manual, not the contract.

Does the contract have a binding clause that prevents you from filing a lawsuit in the event of a dispute? If so, Irvine suggests you negotiate to remove it.

Will the plan notify you in writing 30 days in advance of any policy change? That’s a good clause for you to have.

Can you write a 90 day out clause into contract? If you find your practice losing money once you’re under the contract, the 90 day out clause allows you to cancel the contract before the contract is out, even without cause, says Irvine.