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Tip: 10 contract tips for patient access

Patient Financial Services Weekly Advisor, October 1, 2004

Contract issues related to the patient access area are often prevalent, and they cause denials down the road, says Cassandra Crowal, director of revenue enhancement and access services at MidState Medical Center in Meriden, CT.

To help reduce denials related to front-end processes, make sure the following points are covered in your contracts with insurers:

1. A service that is medically necessary should be covered even if authorization is missing

2. A clause that prevents an insurer from penalizing the hospital if the patient did not or cannot identify his/her plan at the time the service is rendered

3. Unreasonable notification obligations should be avoided for elective admissions

4. Avoid coordination of benefits rules that would delay reimbursement

5. Include a process-payment clause for inaccurate eligibility information that is provided by a payer

6. Communication for notification will be electronic, and the day will be authorized unless the hospital is contacted by a payer at a designated time (the onus is on the payer)

7. Define payment discount for products within the same payer (HMO v. PPO).

8. Understand timely filing rules

9. Specify that changes to the insurance manual will not occur unless the hospital has reviewed and agreed upon the changes (the CFO would lead this effort)

10. State in contract that the version of the insurance manual in effect at time of execution will apply

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