Physicians Practice - January 2008 - (Page 74)

CME FINANCE TABLE 1 RATING YOUR PAYERS Score each payer’s performance in the categories listed below. Remember, lower scores are better. CATEGORY Percentage of denials Size of “hassle folder” Modifier changes Transparency Telephone on-hold time Quality of staff Web functionality Number of medical reviews Revenue per RVU Aging A/R Allowables compliance Response to appeals Credentialing Referral and authorization processes Arbitrary decisions Overly selective labs Third-party authorization reviews Confusing EOBs Uninformative insurance cards TOTAL SCORE RATING CATEGORIES EXPLAINED • Percentage of denials: Assuming your PAYER C 0 0 0 0 +1 0 +1 0 0 0 0 0 0 0 0 0 0 0 0 +2 PAYER A 0 0 +1 +1 -1 -1 -1 0 +1 -1 0 0 0 0 0 0 0 0 -1 –2 PAYER B -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 –19 PAYER D +1 +1 +1 +1 +1 +1 +1 +1 +1 +1 +1 +1 +1 +1 +1 +1 +1 +1 +1 +19 treatment and charging patterns are consistent across all patients from all payers, then how often claims are denied compared to Medicare is a good yardstick. “If the Medicaid carrier denies 42 percent of your claims while other payers deny just 8 percent then you know something’s wrong,” says Woodcock. • Size of “hassle folder”: Ask your business ofﬁce to write a note on payers whenever something odd or bothersome occurs. Keep separate folders for each payer. Review the folders each quarter. “You’ll get a better sense of which ones bring more hassles, plus have real-life examples to use in your next contract negotiations,” says Woodcock. • Modiﬁer changes: Tell your payment posters to be on alert for payers that change how they handle coding modiﬁers. This is one area in which specialties with more coding complexities, such as radiology, may ﬁnd contract management software worth the cost. IN SUMMARY Physicians should look beyond reimbursement rates when assessing health services contracts that they’ve signed with payers. A payer that causes your staff to spend a great deal of extra time to process and obtain reimbursement for medical claims is just increasing your overhead costs. By looking at both the tangible and intangible costs of dealing with each of your payers, you can get a better idea of which ones are worth keeping in your practice’s payer mix. Judging a payer’s hassle factor can be based on several measurements, including: • Fee schedule transparency • Percentage of denied claims • Quality of staff communication • Number of medical reviews • Physician credentialing time • Response to claims appeals • Authorization and referral processes 74 | PHYSICIANS PRACTICE | JANUARY 2008 than Medicare. Guidance for evaluating each category of performance is provided in the sidebar, “Rating Categories Explained.” Why use Medicare as your yardstick? Although physicians may complain about Medicare reimbursement, the program’s impact on staff time and ﬁnances are known and consistent, says Woodcock. “Things are black and white with Medicare,” she says. Keep in mind that this exercise doesn’t weight any of the categories. That is, a payer may rate poorly in only one or two categories, but those difﬁculties could just be too disruptive and costly to be worth the bother. On the other hand, some payers with several average or poor ratings might be too integral to your practice to abandon. MONEY ISN’T EVERYTHING • Transparency: Does the payer provide a realistic competitive fee schedule up front? “If somebody is secretive about their fee schedule I won’t ever consider them,” says Happold-Latham. • Telephone on-hold time: Can your staff get the payer on the phone promptly when they have questions? • Quality of staff: Are the payer’s staff knowledgeable, or do you often end up speaking to someone who is in training or provides incorrect answers? • Web functionality: Can you check patient coverage and eligibility online? Can you ﬁle appeals online? “The payer’s Web functionality streamlines your practice’s operations and makes you more efﬁcient,” says Woodcock. • Number of medical reviews: Does this payer put a larger percentage of claims in medical review than other payers do? “Some reviews are legit, but some payers just want to get around a state’s prompt payment time limits when there’s a loophole that doesn’t count [the time it takes to conduct] a medical review against the deadline,” Woodcock says. An alternative approach would be to set the scale according to the payers at the extreme high and low ends of performance and assign relative scores to the rest. For example, give a +5 to WWW.PHYSICIANSPRACTICE.COM http://WWW.PHYSICIANSPRACTICE.COM

Table of Contents Feed for the Digital Edition of Physicians Practice - January 2008

Physicians Practice - January 2008 Contents The Bigger Picture: Fixing Medicaid Letters Physicians Practice Pearls: You Can Teach an Old Dog New Tricks Noteworthy Cover Story: Fee Schedule Survey: 2007 Results Adding Ancillaries: Bucking the Practice Ask the Experts Idealab: 'How I Got Over My EMR Excuses' Technology: Don't Be Denied The Tech Doctor: Blessing or Curse? The Administrator's Desk: Learning From the Best Coding Career: To Partner, or Not? Management: Controlling Your Inventory Human Resources: How to Fire an Enployee Finance: Beyond Reimbursment - How to Fix Your Mix Classifieds Advertiser Index

Physicians Practice - January 2008

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