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Insurance Payer Contracts: 9 Things You Need to Know

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Like so many medical practices and clinics, you most likely make regular use of insurance payer contracts in your dealings with both providers and patients. But these necessary arrangements can present you with all sorts of hidden pitfalls if you don't understand them thoroughly from the beginning.

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Start by making sure that you know the answers to the following 9 questions:

1. How Long Do You Have to Submit Your Claim?

It's critical to know exactly how many days you have to submit a claim to the insurance provider. Even a single day over the deadline can place your claim outside the service window, prompting a rejection.

2. How Long Does the Payer Have to Reimburse You?

You're not the only participant who must follow a schedule; your payer must also conform to a deadline for reimbursing your medical office. Make certain that your office is including this cutoff date in its accounting plans, forecasts, and procedures.

3. What Services Will the Insurance Provider Cover?

Different insurance providers may include or exclude all kinds of services above and beyond the established essentials, including a few that might surprise you and your patient. Get the facts beforehand so that you can work with the patient on payment options.

4. How Much Will the Provider Pay for Each Covered Service?

Even covered services may only be covered to specified dollar amounts or percentages. Use the information about these limits to help devise payment arrangements for patients.

5. How Should You Dispute a Denied Claim?

You can expect a certain number of claims to be met with initial rejection by your insurance provider. What's the protocol for dealing with claims disputed by that payer? The more efficiently you can handle such disputes, the more quickly and smoothly the billing process will go. Make sure your team is well versed in each provider's rules and requirements.

6. What Are the Rules for Contract Renegotiations and Terminations?

You should always know when your contract is up for renegotiation, especially if it's not set for automatic renewal. If your relationship with your payer isn't working out, you'd better know what it will cost you to terminate that contract and how much advance notice you're required to give. Without careful planning, you might find that your undesirable contract has auto-renewed on you.

7. What Does the Provider Require for a Clean Claim?

How does your insurance provider define a clean claim? What amount of detail is necessary for the information and verifications you submit with each claim? The more clearly you understand these requirements, and the more closely you adhere to them, the more easily your claims will be processed and the fewer rejections you'll have to tangle with.

8. How Do You Meet the Provider's Network Requirements?

If you want to be included in a particular payer network, keep in mind that different payers may have different requirements regarding licensing, certifications, special training or other clinic/practitioner qualifications. Find out what your payer demands of you so you can determine whether it's worth taking those extra steps.

9. How Will You Follow Term Updates and Rate Changes?

Insurance providers routinely update their terms, conditions, and rates, and in many states, the providers are under no obligation to notify the medical offices. Miscommunication in this area may lead to disputes and claim processing snags. Have your administrative team develop a system for monitoring provider terms, conditions and payments so any changes will get noticed and addressed immediately.

Maintaining the right processes and tools can greatly assist your efforts to keep on top of your payer contracts. Contact PCIS GOLD to find out how our practice management and EHR services can help!