Know Your Contract, Plan Rules to Minimize Underpayments and Denials

February 1, 2014

Denials plague every physician practice, but there are ways to keep the hassle to a minimum. It sounds simple sometimes when we say it, but the way to keep denials as low as possible is to follow the rules to the letter. However, it’s not really simple because you probably have many plans with different rules and submitting a claim isn’t the same from one plan to another.

Physicians should be particularly vigilant about making sure negotiated rates have been loaded correctly in the payer’s system and that all the providers in the practice are correctly linked to those rates. Periodically request that the plan give you a copy of the provider file it maintains for your practice so you can check it for errors and update it as necessary.

The most common reasons for denials are medical necessity, denial due to failure to comply with a plan requirement such as referral, authorization, or timely filing; and an apparent claims processing error by the plan. The most common reasons for underpayments are the plan’s failure to load negotiated rates correctly, the plan’s failure to link a provider to the correct negotiated rates in the claims system, a plan’s failure to implement an automatic annual rate escalator, bundling and payment policy disputes, and downcoding.

To avoid these issues, try following these issues:

  • Become familiar with the plan’s provider manual and policies as best you can. Know the authorization and referral rules and abide by them. Additionally, make sure you’re aware of the plan’s bundling and payment policies.
  • If you have negotiated custom rates with the plan, press the plan to test some claims upon initial loading and keep a careful eye on claims at the outset to ensure they are being paid accurately.
  • Make sure your medical record documentation is completely up to date, accurate, and comprehensive so you are in a better position to dispute any proposed downcoding.

Inevitably, some claims will be denied or reimbursed at a lower rate than expected. What do you do when it goes wrong? First don’t be late – Make sure you have a process in place to submit appeals or payment adjustment requests within required time frames. Be familiar with appeals processes under your contract with the payer and applicable law, including time frames for filing appeals.

Have a process for tracking date of receipt of denials and underpayments as well as bucketing them by payer and reason. Document all correspondence and calls you undergo with plans. Beware of lookback periods for payment adjustments, either in contract or in law. Some lookback periods are as short as 45 days from date of payment for the provider. (Note that the time frame for appeal of a denial is often different from the time frame for requesting an adjustment to an erroneous payment.

Develop good working relationships with your provider relations representatives. Try to keep in mind the value of these relationships, especially when you are frustrated. Remember, you want these people on your side. They’re human and are being bombarded by provider issues all day long—stay in their good graces and you may find you get better and faster responses. Abuse them, though, and your issues may never see the light of day without legal intervention.

Follow the applicable procedural requirements for individual claims. However, if you find that you have recurring issues, you should, in addition, provide spreadsheets to your provider relations rep that illustrate the problems and identify the amount at issue.

Finally, remember the longer you wait to raise an issue, the less likely you are to be fully compensated. Why? Older claims fall outside the lookback period, and you may end up settling a number of claims together at a discounted rate, or you may waive prompt pay interest in order to close out the settlement negotiations. By raising an issue early, you can hopefully start the resolution process earlier.

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