Payers

This is the first in a series of letters to use for patient collections.

Physician profiling is used by payers to steer their members to in-network physicians who, by their measures, are the most cost-efficient and provide the highest quality of care. Wonder if you’ve made the grade? Look yourself up in a provider directory: if you see a star or two beside your name, you’ve been profiled.

In the current economic environment, physicians across the country may soon be facing pressure - not only from Medicare, but also from commercial payers - to lower their incomes substantially.

Our fifth edition of PayerView uses real claims data to examine and rank payers based on financial and administrative performance, as well as efficiency. Here’s to friendly competition that helps docs get paid.

Hba1c machines are fairly easy to use, they don’t take up a lot of staff or physician time, and allegedly they are decently reimbursed by most albeit not all payers. The machine is free, but the consumables are not. So after expenses, net reimbursement is about $5.

Knowledge is power in the payer game. Expert Lucien Roberts explains how to evaluate your payers and then use that information to negotiate better reimbursements.

I attended a managed-care business forum in Washington a couple of weeks ago to find out what initiatives payers have been working on recently.

Consultant Susanne Madden offers a step-by-step guide to handling payer take-backs and not getting bullied into writing a check without researching the situation.

Like it or not, given our weakened economy, medical practices no longer have the option of relying on self-referrals to guarantee that patients (and payers) will continue to line up at their doors.

There are many intangibles to consider before sitting at the table with a payer to negotiate reimbursement.

Payers have been investing heavily in technology to help manage data and keep their costs to a minimum.

Payer requests for refunds for incorrectly processed claims are endemic. But wait! There are some things you can do before you write that check.

Say goodbye to photocopies: Machine-readable cards could make billing and collections easier. When will payers make them widely available?

Which payers should you deal with and which should you drop? PayerView uses real claims data to rank them first to worst.

I just got a refund request from a payer. It’s for close to $1,000 for a patient we saw from 2004 to 2007. The payer now says the patient wasn’t eligible then. We checked, and it turns out the patient actually was on a Medicaid managed care plan and was not with the payer we billed. Still, Medicaid won’t consider claims from 2004. I just do not know what my options are. Are there any regulations to prevent this?

Could you please tell me how to negotiate higher reimbursements from commercial payers?

I started an urgent care clinic. The insurance companies will not recognize us even though I have gone through the expense to make the facility equal to a small ER. How do I get acceptance from the insurance companies?