It Pays – Literally- to Know Your Insurance Carriers
Know Your Insurance Carriers
The old adage “It’s not what you know, it’s who you know,” is certainly true when it comes to knowing your playing field, and your insurance companies. It’s important to know who you are working with. In fact, your revenue depends on it. Knowing the intricacies of different insurance carriers should be at the core of your medical billing programs. It can make the difference between the successful processing of claims or multiple rejections.
Did you know that the American Medical Association publishes an annual report card of the claims revenue cycle activities of the major commercial health insurers and CMS? It reports the timeliness, transparency and accuracy of claims processing of these payers. In other words, it helps you to know your playing field with important details. This information can be used to improve your reimbursements. You just need to know how. MICI does. Here are some specific examples.
1) The report card shows:
The median time period in days, between the date the physician claim was received by the payer and the date the payer produced the first ERA.
With this information it is possible to track claims to speed them along the payment track. If the claim is not paid within the expected time, it should be flagged, put in a claims queue and be followed up on, then checked in assigned intervals until paid as part of your medical billing process.
2) The report card shows:
On what percentage of claim lines does the payer’s allowed amount equal the practice’s expected allowed amount?
You need an expert to look at every claim that is paid to your practice and the amount that is paid. Do the paid fees match the expected fees? If not, the reasons for the discrepancy need to be tracked down quickly, and the full payment due (and contracted for) needs to be sought- relentlessly.
3) The report card shows:
What percentage of claim lines submitted are denied by the payer for reasons other than a claim edit?
Using the national report card, one can understand where errors in claims processing might occur, reconcile them, work to ensure the errors don’t recur, and get the reimbursement paid.
You also need to know the playing field for managed care contracts.
These contracts are complex and critically important. It takes skill and diligence to obtain, maintain and renegotiate strong managed care contracts. It also takes time and experience to ensure that you are getting paid according to the terms of the contract. Pursuing denials takes time—time that physicians should be spending with patients.
What is the reason for the denial? Was it:
- Managed care contract paid incorrectly
- Appeals for information provided incorrectly
- Carrier denied for medical reasons
- Eligibility for the patient
Without an expert revenue cycle management company on your side to appeal denials and then make system corrections to reduce reoccurrence, you may be leaving thousands of dollars on the table. MICI will help you to know your playing field, and win. We will implement proven revenue management solutions that will increase the profitability of your medical practice. Our efficiency and relentless determination are on your side.
It’s a complicated world out there. We can make it simpler for you.