:: Third Party Contract Management ::

Is there a separate file for each of your top payer agreements? For most practices, four or five carriers represent 80 - 90% of their commercial business. All official correspondence or staff notes relating to the payer should be kept in these files. Most practices participate with a lot of carriers, but can't even locate the signed agreements.

Is there a current fee schedule attached? Do not accept agreements that refer to the rates from a previous agreement or that allow the carrier to adjust the fees during the term of the agreement. While no carrier can be expected to provide you with every procedure fee, you should at least know the fees for your top 15 or so procedures. If you participate with carriers through an IPA, you can get the fee schedules from them.

Is someone reviewing the files, at least annually, and then presenting a summary to the partners? It doesn't take long. There may be an inordinate amount of problems relative to the volume of business you have with a particular carrier. You may want to reconsider renewing unless the carrier can resolve the administrative problems or improve certain fees. Most agreements automatically renew if a practice doesn't notify the payer by a certain deadline. Don't let any agreement, especially a high volume one, automatically renew without reviewing it first.

Do you have established or logical criteria for participation with an existing or new carrier? Are there enough covered lives to make it worthwhile? Are a lot of the employers in the area offering the plan? Is the reimbursement schedule adequate? Is it easy to do business with them? Do they pay on time? Do practices you refer business to, or practices that refer business to you, participate with the carrier?

Are you aware of what major insurances in your market you are accepting? Does your support staff know? Billing clerks need to know what patients can be balance billed because the practice does not have an agreement with their carrier. Receptionists need to know what plans require their members to make a co-pay at the time of service. Schedulers need to inform new patients. I often been told by managers they do not par with a particular carrier because they haven't signed an agreement or don't remember signing one. Yet, the practice has been accepting the carrier's fee as payment in full.

Is anyone reviewing the billing process? Are copays collected the day of service? Were you paid according to the payer's agreement? Were you paid within 30 days? Is there a pattern of being denied? Are patients balanced billed for carriers you don't par with? Did you bill for everything that was provided?

When was the last time you updated your fee schedule? Does it make sense relative to what the market is paying for services? All payers reimburse you the lower of your charge or their fee. Often, upon an audit, you will discover that you are being paid your charge. Do not be lulled into a false sense of security if your IPA has negotiated fees on your behalf. Are you being paid according to what was negotiated, or what you charged?

Is your practice manager too busy to do a reasonable review of the billing process? Then we suggest an independent review. It is relatively inexpensive and cost effective; especially considering how much cash is at stake. An experienced reviewer will pinpoint "leaks", offer recommendations to close them and act as a confidential sounding board to your manager.