Oh, the rules we have to follow in healthcare. I'm not talking about laws, but payer rules. There is so much to know and it often changes. How are providers supposed to keep up? I use a lot of "cheat sheets" to help providers understand payer specific mandates.
Here are some examples of what to look out for:
• If you are paid a flat contracted rate of up to $75 per visit, but your provider only codes $60, that payer with that rule will only pay you $60.
• Some payers require you to submit a prescription every thirty days along with chart notes.
• There are payers that "cascade" their codes. For instance, they pay 100 percent of the first code, 80 percent of the second code, and 40 percent of any remaining codes. Be sure your billing software puts those codes in order of highest paying to lowest paying to insure you are being paid at your maximum.
• We have a payer that only allows an evaluation code every six months. If you have a patient that comes in more than this, you will not be paid for that code.
• There is a payer that only allows providers to bill four units per day. Anything more will not be paid and the payer may deny the entire claim on first pass, making provider spend precious resources following up on that unpaid claim.
• Some payers do not pay on specific codes. If you code those, they will be denied.
• If you are contracted with another payer, they require authorization after a specific number of visits, do you know which one?
• Some Worker's Compensation patients require separate authorizations for specific tests, rehabilitation, and physician visits. Often, providers assume that one authorization covers everything. Read the authorization provided, if what you want to do is not on that authorization, call the nurse case manager and ask for it to be added.
• Patients who use their Medpay often have a cap amount, ask the patient the cap amount to be sure you are not exceeding it.
• Along with Medpay, once that cap amount has been exceeded, you can call the patients private insurance company, inform them Medpay has been exhausted, and ask if the patient can now use their plan benefits. In the event you do not ask this, you run the risk of the plan finding out and either asking for a refund, or just taking the money back from a future payment. Yes, this happens.
• Some plans require specific "modifiers" to be added prior to payment.
• Check your Fee Schedule to make sure that you are being reimbursed the maximum amount by payers. If you have $100 for a service, and payers actually reimburse at $125 for that service, you are losing money.
It's very easy to not know and understand your payer rules, but having someone review these twice yearly can save you thousands of dollars on first pass recovery rates, and save you thousands more on the back-end for having to manage those denied claims.