Is This Seat Taken?
Does Managed Care contracting have a seat at your denials management table? If not, your organization is missing opportunities to prevent denials and capture revenue. Negotiating payer contracts to benefit the provider should be what the managed care contracting department is focused on, but they don’t know what they don’t know. This is where the invite to the table is necessary. Revenue Cycle needs to partner with Managed Care contracting to ensure proper language is written in the payer contracts to prevent and minimize denials. So what items should be included in payer/provider contracts?
Medical Policy Bulletin
The Medical Policy Bulletin is the document created by payers that outlines the process for medical necessity determination and sets parameters for clinical review schedules. For services paid on a Diagnosis Related Group (DRG) basis, providers should ask the payer to specify that no additional clinicals are due after day 1 approval unless the admission reaches the outlier or dollar threshold. Another consideration, regarding the Medical Policy Bulletin, is to include wording that states “any changes made by the payer to the MPB, need to be communicated to the provider a certain number of days prior to the start of the new process or requirement. Since the MPB is not always written in a way to benefit the provider, it is important, from a denials management perspective, for the provider to be aware of any changes to maintain compliance and prevent denials.
Access to Electronic Health Record (EHR)
Hospitals should allow payers to have access to the hospital’s EHR to retrieve admission information about their members. Once a payer is “notified on admission” about one of their members becoming a patient, the nurses or case managers at the payer should be able to access the hospital’s EHR, eliminating the need for the hospital to provide clinicals and risk a denial from clinicals being late or insufficient. It is amazing how many times clinicals from the hospital find their way into a “blackhole” and never make it to the payer resulting in a denial.
Implants and High-End Drugs
Depending on the type of services a hospital provides, there may be an opportunity to decrease denials and recoup extra dollars when it comes to implants and high-end drugs. Hospitals should negotiate a carve out for high end drugs and implants on an inpatient basis, as well as, how implants are to be paid on an outpatient basis.
IP Only Lists
Inpatient only lists provide a list of procedures that are always considered to be inpatient by the payer. Some payers use MCG and some use InterQual to determine if the admission is inpatient or not. Hospitals should ask, and have it documented in the contract, which criteria guideline the specific payers use. Knowing which criteria the payers use, will enable the hospital to use the same and ultimately prevent patient status denials.
Appeals Submission and Review
Appeals are necessary to make right what was wrong. When a hospital receives a denial and does not agree with it, this is where the appeals process starts. The appeal is a way for the provider to play the game; to fight for the money that is owed to them for the services provided to patients whom met medical necessity. The appeals process, dictated by the payer, is burdensome to the provider. When negotiating a managed care contract, providers should ask for the payer to make it possible for all appeals to be submitted electronically and for all supporting medical documentation to be uploaded through the payer website. This would minimize timely filing denials.
In addition to a better way of submitting denials, providers should also negotiate a timely review process from the payer. Meaning that the payer requires that providers submit appeals in a defined timeline, but the payer review process has no defined timeline. The provider must jump through hoops and the payer does not.
Contract Changes = Money
Contracts mean money. Just because a provider has a 3-year contract does not mean the contract is put on the shelf and forgotten about for 3 years. The payer contract needs to be a dynamic document. One in which is consistently referred to by the provider to identify denial prevention opportunities. The contract needs to be written in a way to make it easy for the provider to do business with the payer. By forming a collaborative relationship between Revenue Cycle and Managed Care Contracting, any contractual changes that need to be made to reduce denials and increase reimbursement can be communicated at the time of renewal. It is imperative that Managed Care Contracting have a seat at the table. Is this seat taken?
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