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From the Desk of Trish Peters
NEW
Trish's Monthly Managed Care Forum
I would like to introduce to you and invite you to
participate in my new monthly managed care
discussion and forum. This will be "live" via a
webconference and it will only last for 30 minutes. On
the 1st and 2nd week of the month, I will
send out an invitation to our audience to request and
query for items of discussion or questions that need to
be answered regarding managed care and
contracting. On the 3rd Wednesday at 12:00pm Noon
Central Time, we will hold a webconference meeting.
This forum will be totally free to attend and will allow
you a chance to get engaged in lively discussions that
are sure to effect how you manage your practice or
ASC.
Click for My May 19 Forum
Survey
Click to Go Directly to May 19 Forum
Registration
NEED TO KNOW HEALTHCARE/MANAGED
CARE UPDATES AND TIPS:
- Medicare Cuts Delayed
On April 15th the Senate approved a temporary fix for
the planned 21.3% Medicare physician fee cut. The fix
will delay implementing the Sustainable Growth Rate
formula until June 1st.
- Primary Care Physician Shortage
In a major feature the Tennessean reports "the nation
is short about 16,663 primary care doctors and by
2025 that number will reach 140,000 according to the
American Academy of Family Physicians".
- www.hmosettl
ements.com
Is a site that serves as a source for information about
the Settlements reached between representatives of
over 900,000 physicians, state and county medical
societies with the Blue Cross Blue Shield Association
and over 90% of the Blue Cross Blue Shield health
plans in the Love, et al, v. Blue Cross Blue Shield
Association, et al,litigation, and with Aetna, CIGNA,
Health Net Inc., Prudential Insurance Company of
America, Anthem Inc./WellPoint, and Humana Inc. in
the In re Managed Care Litigation.
- A Massachusetts judge denies six health
insurers request for double-digit rate hikes for tens of
thousands of small businesses and individuals. The
health insurers are pursing appeals within the
Division of Insurance.
Managed Care companies shares
Click for managed care
company latest stock activity.
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Greetings Doctor, ASC Administrator and/ or Directors!
Hi, this is Trish Peters, the Director of Managed
Care at Excellentia Advisory Group.
If you have attended one of my Managed Care
webinars regarding ASC or physician contracting, you
will find this newsletter issue an important addendum
to the information that you have already received from
me regarding managed care contracting. Also this
newsletter will include new topics regarding managed
care contracting and important healthcare news.
Please check out our Q&A section. This is where we
will continue to post the questions from our ongoing
Managed Care webinars. I am sure at least some of
these same scenarios could be pertinent to YOUR
physician practice or facility!!
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| Questions & Answers from recent webinars |
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Our most recent Managed Care webinars had some
excellent questions from the audience. Click on the
link to see the answers provided by Trish Peters to
these questions....
- How long do we have to request underpayments
from the plans?
- How much time does it take to negotiate a
contract?
- During negotiations, what should we do if the plan
won't budge on their rates?
- What is the typical reimbursement rate you see
offered by the plans?
- When is the best time to ask for more money from
the plans?
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Click for Answers... |
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| DO YOU ANALYZE YOUR CONTRACTS ON A PERIODIC BASIS? |
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If not, you could be losing money.
It's very important for you to know exactly how you
should be paid and that the plans are paying you
according to contract. Your contracts must clearly
define the payment terms. If you are a physician
group, how do you know if the plan is paying you
correctly if the rate exhibit/schedule of your contract
only states "you will be paid in accordance with the
plans market fee schedule" and that's it!
Other questions may be:
- How do you know what site of service the plan
applies?
- What year of Medicare are the rates based on and
will that year be fixed or will it update every year?
- What percentage above Medicare are the rates
based upon?
- How are new procedures established after the
effective date paid?
- If you are an ASC how do you know if you are being
paid correctly if the multiple procedure discount
language is not clearly defined?
- Does the plan pay in accordance with the new
Medicare APC payment system or do they go by the
old ASC groupers?
- Does the plan enhance their groupers or do they
follow the old Medicare groupers?
These are just a few examples of the detail that
should be spelled out in your contracts. After you have
clearly defined the payment terms of a contract and
you know exactly how you should be paid, you need to
periodically analyze the contract to make sure you are
being paid correctly, especially if you don't have a
contract management system. To analyze a contract
you must know how to run reports from your system
and if you can, covert the reports into a data base.
Information from the report will depend on your
systems capability. At a minimum, the detail in the
report should include the account number, date
of service, place of service, CPT-codes, units per CPT
code, charges, payments, balance and adjustments.
Then, in your spreadsheet or database, add the
contract rate and the payment terms and conditions
that apply.
There haven't been too many time where I've analyzed
a contract and haven't found a payment error. Multiple
discounts and the multiple discounts involving carve
out procedures or procedures that fall under the
default rate are the areas where I see most payment
errors. If you do find a payment error, make sure you
contact the plan. Have the contract, examples of
remits, and other information, such as your report
ready for support. Never end a conversation with the
plan until you feel your issues have been resolved and
the payment errors have been fixed.
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