By: Bradley M. Seldin, C0-counsel Guest Contributor
Prohibitions against balance billing Health Maintenance Organization (HMO) patients have been around for more than a decade, but many non-contracted providers to HMO patients still don’t fully understand their rights to payment when it comes to collecting monies from patients and HMO’s.
HMO’s often have predetermined rates they pay to non-contracted healthcare providers; sometimes they are artificially low, do not reflect what is written in the member’s contract, or do not abide by what is required by applicable law. As a result, these providers may end up being underpaid if they don’t have a written contract with the payor and they do not understand the payment methodology being applied to them. This is of particular significance to emergency care providers. ER doctors and hospitals must, by law, provide emergency care without regard to whether the patient has an ability to pay for the treatment received.
Following their provision of emergency care, medical providers often question the payment obligations under the patient’s Health Maintenance Organization contract. If the emergency medical provider has a direct written contract, the reimbursement is governed by that participating provider contract’s reimbursement terms. Continue reading →
While your healthcare business 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 healthcare businesses engage auditors to audit their compliance of claims quarterly or annually. 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, practices and healthcare businesses operate with a much higher rate, and even in the 20-30% range without even knowing it.
When auditing the payer interaction, several components should be included in the 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