HCPro.com: Managed Care Contracting and Reimbursement Advisor

Managed Care Contracting & Reimbursement Advisor tells you exactly what you must know and do to successfully negotiate the best deal with HMOs, PPOs, and other payors - and get bigger and faster reimbursement!

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March 2008 (Volume 5, Issue 3)	view entire issue

Focus on the key reasons payers reject your claims
In February, MCCRA looked at strategies to minimize claims denials from payers by fixing and resubmitting rejections, which occur before the claim is adjudicated. But some denials are inevitable, so practices need effective and appropriate responses. Typically, claims denials fall into one of eight categories, says Elizabeth W. Woodcock, MBA, FACMPE, CPC, an Atlanta-based healthcare author and trainer and a presenter at the Medical Group Management Association's (MGMA) annual conference in Philadelphia in October 2007. The following are ways to manage denials efficiently so you can receive appropriate reimbursement

Prepare for contract clauses defining never events
A burgeoning number of states and hospital associations are establishing policies to not seek payment for hospital-based adverse health events or so-called never events-serious reportable events such as wrong-site surgery. In September 2007, the Minnesota Council of Health Plans and the Minnesota Hospital Association, both in St. Paul, unveiled an agreement endorsed by the Governor's Health Care Cabinet that hospitals in the state will not seek payment from insurers or other parties for any of 28 never events identified by the Washington, DC-based National Quality Forum (NQF).

Other recently-published articles from Managed Care Contracting and Reimbursement Advisor:

Cash in on Medicare bonus for e-prescribing

Involve physicians in your managed care contract negotiations

Use lean cost accounting to examine your cost structure

Bridges to Excellence pays bonuses to docs for implementing medical home

Ensure that contracts cover real-time claims adjudication

Build a defensible fee schedule to challenge lowball payer contracts

Use retail clinic referrals to boost your bottom line

E-visit payment promising but not ready for prime time

Think twice before opting out of Medicare

Prepare for contracting challenges during mergers, consolidations

E-tool: Sample letter to payer on intention to renegotiate

E-tool: Payer/MCO contract provision samples

Watch your contracts in the wake of ’final’ Stark rules

Put these provisions on your managed care contracting hot list

Audit your patient financial services department to maximize your managed care reimbursement

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