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Wednesday, December 8, 2010

Insurance reimbursement rule - reimbursement contract, payer procedures

Understand Reimbursement Rules 

Each health care stakeholder seeks its best service, cost, and outcome solution on a resource scarce playing field. Accordingly, health care's critical role in our modern and aging society has led to the development and constant updating of a huge body of both legislated and interpreted rules. Clearly, each group should start protecting its long-term interests by actively engaging in understanding, implementing, and contributing to the development of these rules. For providers to ensure that they collect what they expect, they need a thorough understanding of reimbursement contracts, payer procedures, and claims denials, and an active management approach to comparing predicted revenue collection to actual collection.

In order to predict revenue collection, providers must establish necessary expertise in each of the following areas:

Reimbursement Contract — Providers have to understand how each reimbursement contract handles varied billing requirements, coverage limitations, facility-specific needs, start and end dates, co-pays, per diem rates, and G/L posting references.

Payer Procedures — Providers have to be intimately familiar with payer procedures. They need to require payers to provide in-service training to provider staff to ensure that they thoroughly understand the payer's procedures. They should insist on receiving initial in-service training for all staff and regular refresher training to bring new staff up to speed on updates and procedure changes. Payer educational materials should be saved for reference. Providers should also develop and systematically maintain a library of provider manuals. Provider staff should be provided with all the tools and information they need to work under the payer procedures, including all payer addresses and phone numbers required for notifications, authorizations, claims, and collection follow-up.

Claim Denials —
Philosophy and technology should be combined to manage claim denials and achieve predicted revenue collection. Understanding and documenting reimbursement contracts and payer procedures is largely dependent on providers negotiating effective contracts and training their personnel on how to follow the rules. The range of reimbursement and compliance rules is great, but there is no substitute for understanding.

Reimbursement claim denials are variances to the patient encounter revenue-collection plan. In order to reduce these variances, providers need to follow an active and systematic approach: analyzing and prioritizing denial causes; establishing a plan; assigning responsibility; tracking appeal processes according to contracts and payer procedures; and introducing business rules that identify and correct processing problems upstream in patient encounters, thereby preventing denials in the first place.

The potential to use technology is greatest in the area of claim denial management. When providers add automated and collaborative goal setting, business planning, and accountability to the passive measurement of revenue collection, they create forward-looking and inherently active management that increases revenue predictability.

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