October, 2021 | PractiSynergy: From Medical Billing to Practice Management

Payer Credentialing And Contracts

Payer credentialing and contracting process – Yawn! The most boring topic – Yet one of the most important for medical providers. The process is laborious and tedious.

Gathering paperwork, filling out forms, and negotiating is not how most professionals want to spend their time, unless of course they are attorneys or accountants 😉

The process is meant for the payers to “vet” medical providers and make sure they are legit. (Wiki: Credentialing)

The process also allows the provider, to align themselves with different employer groups or accountable health organizations for exposure and marketing of their practice.

Why are some networks so narrow? These networks are aiming for a truly patient centered experience. The primary care provider and the patient would make decisions together for the best course of treatment. Specialists need to decide what groups might have the biggest impact on your bottom line.

That is where the negotiating comes in. In a narrow network, the specialists need to prove their worth and may have to jump through extra hoops or make certain concessions in contract negotiations to become an in-network provider.

Is it so bad to be out of network? If you are out of network, most commercial insurance plans have an entirely separate set of benefits. Patients typically have separate (and large) deductibles and out-of-pocket maximums for out of network providers.

While the insurance company may “allow” the full fee of your service instead of a negotiated discount that an in-network provider might receive – this balance typically falls on the patient.

The patient becomes responsible for the entire balance. Large medical bills are extremely scary for patients.

Scary may not even be the correct term – if they don’t know it is coming, they can be outright mad. Collecting money from patients is typically much more difficult than collecting from an insurance company.

Why aren’t there set fee schedules which all insurance companies just pay the same [Pay transparency]? That is a discussion we all need to continuously be asking our legislators. Until the “system” changes this is the game – if you don’t play, other will. PractiSynergy understands and knows how to play this game. We guide providers in revenue cycle management to maximize their profits. This all starts with contracts and credentialing.

Want to get in the game and learn more about credentialing and contract negotiations?

Call Katie at PractiSynergy or reach out via Email to receive a FREE CONSULTATION on how PractiSynergy might help your practice maximize revenues through payer contracting and credentialing strategies.

Medical Code Commodity

The Merriam-Webster dictionary defines commodity as “something useful or valued.” In healthcare, coding is the most important yet silent commodity in the revenue cycle. So, what is Medical Coding Commodity and why is it essential? Let’s understand it…

With over 68,000 ICD-10-CM medical diagnosis codes and over 87,000 ICD-10-PCS procedure codes for providers to comb through, selecting the right combination of diagnosis and procedure codes can be a daunting task.

Medicare and other major insurance companies have their own “billing guidelines” which must be followed to get paid. Certified coders know where to look for the information to find what diagnoses may be used to determine medical necessity for various procedures.

For instance, Botox®, this drug is covered by Medicare and most insurance companies for Migraines, but they will not pay for it if you want to smooth out your facial wrinkles.

Most providers do not have the time to look up if a specific diagnosis is payable for each appointment, certified coders are essential to getting providers paid.

Electronic Medical Records (EMR) and Practice Management systems are supposed to assist with coding however, the EMR does not have the experience working with insurance companies who may have different policies on how to code a single procedure. Some insurers may require a modifier – while some may not.

Some may only pay when a procedure is paired with a certain diagnosis – while some may be flexible. Each insurer is different, and each state may also have different guidelines.

Certified professional coders added into a revenue cycle allows a critical view on a patient encounter prior to being sent to payers.

Coders can focus on certain specialties such as orthopedics, podiatry, optometry, etc. garnering experience from the different insurance companies and maximize payment for the providers on the first pass of a claim.

When a provider is searching for the right code that is time they are not spending with their patient. Any process improvement program would tell you wasted time/wasted resources is inefficient. Inefficiency can cause a debilitating effect on a medical practice.

Investing in an experienced coder will more than pay for itself by maximizing reimbursement and decreasing claim denials.

PractiSynergy has Certified Professional Coders (CPC) on our team reviewing procedure notes and providing education on documentation to providers to ensure compliance.

The combination of a CPC and experienced biller will improve compliance and increase cash flow, maximizing a clinic’s profits.

To tap into this “Coding Commodity”:

Call Katie at PractiSynergy 515.635.5531 or email katie@wordpress-799426-3758877.cloudwaysapps.com

Receive a Free Consultation on how PractiSynergy might help your practice maximize revenues and boost your cash flow.