Step Two: Deciphering Your Payor Contracts

microscopeOnce you have obtained a copy of the signed and executed contract from the payor, review the document carefully to ensure that it is signed and executed by both parties. As you review the contract you may wish to summarize key information on a cover sheet that includes all major terms. Many practices make the mistake of ONLY looking at the fee schedule when deciding whether to contract with a payor. It’s equally important to review their payment rules, medical policies, etc. If, for example, the payor has a medical policy that a certain procedure you perform frequently is investigational/experimental and therefore not payable, the reimbursement rate doesn’t matter. Important key information to obtain and make notes of includes: Effective Date, Term and Termination The effective date of the contract is typically located in the first paragraph or near the final signature page of your contract. The length of the agreement and details about when, and under what circumstances, the contract may be terminated are usually included in a Termination section towards the end of the agreement. Nature and Scope of Services Provided Confirm that the services that you are obligated to provide through this agreement are services that your practice provides. If you provide services that do not typically fall within your specialty, you will want to make sure these services are included in your contract and that the reimbursement for these services is specified. Rates/Fee Schedule A complete fee schedule for contracting physicians should contain the amount of payment for the services to be provided under the contract, including other factors and/or units used when determining the fees for each and every service. It’s also important to understand the payment methodology that governs reimbursement for codes not listed, drug pricing, immunizations, high-tech radiology, etc. Compare your fee schedule to the payor’s reimbursement rate, with special focus on your high-volume and high cost codes. Beware of payors who only offer a “sample” fee schedule list that only includes a limited number of CPT codes and price. Physicians are entitled to a complete list of reimbursement rates for every service that they may be contractually obligated to provide. Rules and Guidelines for Payment Payment and medical policies used to adjudicate claims (i.e. bundling, multiple procedure reductions, modifiers, etc.) are essential in setting clear expectations for the practice from the time a claim is billed to the time of payment. It’s important to know in advance how each payor will reimburse your claims. Pre-certification/Prior Authorization Confirm which services require prior authorization and how it is accomplished. Claim Submission Requirements Confirm the claim submission deadline, where and how to transmit, and which services require medical record documentation, etc. upon submission. Claims Contact Confirm contact information for your local provider relations representative tasked with providing assistance when you are having difficulty resolving payment issues on a claim. Verify the contact’s name, telephone number and email address. Provider Dispute Resolution Process Confirm how and where to submit appeals as well as the timeframes for submission of appeals at each level. Contract Attachments/Exhibits Many payors are moving key sections in their agreement to the policy and/or procedure manual. Contracts frequently reference the plan’s provider manual, medical policy manual or other documents. These documents are typically incorporated as part of the contract, which means that a physician is contractually bound to the terms that exist in these manuals, in addition to those in the contract. Physicians should obtain provider manuals and plan administrative policies and procedures from all payors, as they may impose considerable obligations and restrictions on physicians.

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