How does a practice or any health care provider really know for sure it is receiving the correct reimbursement from its managed care payors? According to an informal polling of practitioners at a recent health care conference, over 50% of the participants indicated errors have been found with regard to what the medical practice was contracted to receive as payment and what the managed care company actually paid for the service. For example, the practice was contracted to receive $44 for visit code 99213 from ABC Managed Care Company but the Explanation of Benefit (EOB) indicated only $38 was paid.
Unfortunately, this type of situation seems to be occurring with increasing frequency. It affects not only physician medical practices, but all health care providers as well, including hospitals, health care facilities, and other health care service providers.
Managed care companies do make mistakes and it is up to the health care provider to catch these mistakes and file an appeal for the additional reimbursement. Catching reimbursement errors can be extremely difficult for many providers, especially smaller service providers. This includes the one to two doctor medical offices. Small practices or health care providers often do not have the time nor the personnel to pay attention to this type of activity, as important as it now is. However, a good software system in place can usually catch these reimbursement errors.