Managed Care Oversight
Managed Care Consulting
Feb 28

Managed Care Oversight

Managed Care Oversight

You have payer relationships so I ask: How is your current managed care oversight? While your medical practice may be compliant with billing regulations and coding, this does not mean that your payer is compliant and has paid you correctly per your contract.  Providers know that Fraud and Abuse has been one of the largest areas of focus for payers and the government over the past 20 years.  Due to this attention, many medical practices engage auditors to audit their compliance of claims quarterly or annually (Something I strongly believe in!).  However, in addition to compliance audits, a provider should be auditing their payer interaction to create a dynamic blueprint of denial management and payment recovery.   The AMA states that a 5% denial rate for an average family practice equates to about $30,000 walking of the door.  A good benchmark for payer compliance would be a denial rate of 5-10%.  Often times, medical practices and other healthcare businesses operate with a much higher rate, and even in the 20-30% range without even knowing it.

What Should You Review

With managed care oversight, several components should be included in your ongoing review including:

  • Denial rate percentage
  • Aging of claims paid for 30 day, 60 day, 90 day, over 120 day period as an Aggregate
  • Aging of claims paid for 30 day, 60 day, 90 day, over 120 day period by each Payer
  • Claims denied categorized by denial reason as an Aggregate for previous 12 months
  • Claims denied categorized by denial reason by each Payer for previous 12 months
  • Claims that have been appealed, the date submitted, the date of the outcome, the outcome by each Payer
  • Claims not paid according to fee schedule as an Aggregate for previous 12 months
  • Claims not paid according to fee schedule by each Payer for previous 12 months

Dealing with Payment Issues

Once this initial managed care oversight review is complete, you now have a baseline for your payer’s performance.  A monthly dashboard can be developed by your office manager, billing manager or billing company with these components to monitor these metrics now on a monthly basis.  This approach will lend a proactive approach to detect payer problems before they are an epidemic.

Once a payment issue has been identified, disputing this denial or reduction is the next step.  When representing my physicians, I always ask “Help me tell your story”.  To truly advocate, the details of your story need to be documented and include the services denied or reduced, the medical chart that highlights the service that you rendered, the communication with the payer that has occurred both telephonically and written, as well as, any executed contract governing your relationship that may be applicable.

Be Proactive

Now by using financial dashboards, you can now perform managed care oversight. This proactive detection process and using thorough documentation supporting a dispute with a managed care payer, physicians and providers now have the ability to manage their payer relationships.

Additional Resources for Managed Care Oversight

About Reed Tinsley, CPA

As a top advisor to physicians, I help increase practice profits by delivering hands-on, expert medical accounting/tax support, practice counsel, and revenue-building strategies. Read more →