Recently, as I was speaking with one of my colleagues who specializes in reviewing and negotiating agreements with third-party payers, she lamented that no one reads their provider agreement anymore.
I fear that she may be right. Reading a provider contract is not exactly a hoot. If you combine that with the fact that many of the payers have convinced people that the contract is “take it or leave it,” and we have a world where it’s quite common to sign payer agreements without any review whatsoever. But if you listen to the Monitor Mondays segments by Ronald Hirsch, MD, Knicole Emmanuel, and others, you’ve like noticed a pattern. Third-party payer contracts truly demand scrutiny.
Taking a step back, it is good to remember that insurance companies do not have some divine right to impose their own definitions on you. They aren’t inherently authorized to define “inpatient,” whether it is using or rejecting the two-midnight rule. With very limited exceptions, nothing in any federal or state law requires third-party insurers to establish payment rules that mimic or differ from those imposed by Medicare or other insurance companies. The main exception is Medicare Advantage plans, which may not impose a rule that is less generous to beneficiaries than Medicare. In most other situations, whatever the payer is doing, it is doing it by choice. There are times when the variation from Medicare is beneficial to you. But even those beneficial situations come with the administrative burden of trying to implement these disparate rules.
Whether the private payer’s rules are helpful or not, you need to know what they are. Some of the more frustrating legal problems I’ve dealt with involved situations in which my client had failed to read the contract, and didn’t ask us to review it. One example is totally unrelated to third-party payer contracts. I’ve had many clients sign ambulatory surgical center management contracts without careful review. Then, after becoming frustrated with the operation of the management company, they seek to exit the agreement, only to discover that the contract renders that nearly impossible.
Returning to the third-party payer situation, I’ve had a client build an ambulatory surgical center (ASC) only to discover that their biggest private insurer required preapproval before paying any claims at a new location. The insurer refused to credential their new ASC.
Sometimes, the unread terms even prove favorable to clients. I had one client prepared to refund hundreds of thousands of dollars to a private insurer for six years of payments. But they had not noticed that under the agreement, the insurer was only allowed to reopen claims for 12 months. The insurer was seeking six times the money to which they were entitled.
The bottom line is that many disputes are won or lost well before the first demand letter is written. In the world of private insurance, it’s the contract that controls. If you’re not paying attention when the rules are established, you’re missing your best opportunity to make sure you are treated fairly.
Programming Note: David Glaser is a permanent panelist on Monitor Mondays. Listen to his live reporting every Monday at 10-10:30 a.m. EST.
The origins of Health Maintenance Organizations (HMOs) can be traced back to the early 20th century, when prepaid group practice models began to emerge. These
The Children’s Health Insurance Program (CHIP) was created as part of the Balanced Budget Act of 1997 (BBA 97) to provide health insurance to children
Please log in to your account to comment on this article.
Dr. Ronald Hirsch provides tried-and-true strategies and insight into outpatient in hospital bed stays including determining the applicable definition, who uses it, and when and how to bill for this circumstance, solidified with concrete case examples and expert insight.
Practical solutions for CDM departments to protect your hospital’s revenue.
This webcast teaches hospitals how to comply with CMS price transparency rules and compare their rates with peer hospitals. It covers creating a compliant machine-readable file, comparing negotiated rates, and improving pricing decisions.
The No Surprises Act (NSA) presents a challenge for hospitals and providers who must provide Good Faith Estimates (GFEs) for all schedulable services for self-pay and uninsured patients. Compliance is necessary, but few hospitals have been able to fully comply with the requirements despite being a year into the NSA. This webcast provides an overview of the NSA/GFE policy, its impact, and a step-by-step process to adhere to the requirements and avoid non-compliance penalties.
This expert-guided webcast will showcase tips for providers to ensure appropriate capture of the work performed for a visit. Comprehensive examples will be given that demonstrate documentation gaps and how to educate providers on the documentation necessary to appropriately assign a level of service. You will gain clarification on answers regarding emergency department and urgent care coding circumstances as well as a review of how/when it is appropriate to code for E&M in radiology and more.
Set yourself up for financial and compliance success with expert guidance that breaks down the impactful changes including MS-DRG methodology, surgical hierarchy updates, and many new technology add-on payments (NTAPs). Identify areas of potential challenge ahead of time and master solutions for all 2024 Proposed IPPS changes.
Do you struggle with selecting and appending the correct modifier for your medical claims? Join our must-attend webinar, “Mastering Modifier Usage: Preventing Denials and Ensuring Compliance” to reduce claim denials and improve your reimbursement rates.
Kay Piper reviews the guidance and updates coders and CDISs on important information in the AHA’s fourth quarter 2023 ICD-10-CM/PCS Quarterly Coding Clinic in an easy to access on-demand webcast.
Copyright © 2023 ICD10monitor. Powered by MedLearn Media.
