The True Cost of Contract Compliance and Payment Monitoring

Physicians from your newly acquired practices have been onboarded and credentialed. They are seeing patients and starting to generate charges. But Wait! Who’s confirming they are being paid under the guidelines of the organization’s managed care contracts? Here comes the fun part: Contract Compliance and Payment Monitoring. Contract Compliance Audits are the written agreement which defines the terms by which providers offer services to members and the method by which you will be reimbursed for those services. Sounds simple in theory but contract compliance audit programs are complicated and vary state to state. Understanding them is critical. For example, your organization bills Payor A $100,000 per month for services rendered. However, Payor A consistently under pays on your contract by 10% or $10,000 each month. This means your organization is losing upwards of $120,000 per year in underpayments. Surely you would notice that amount of money missing from the coffers! Not necessarily. The problem is the underpayments are spread across hundreds of patient records which means the amount per patient is small and easily overlooked. This is further compounded when you factor in that Payor A is only one of a 100 payors you work with on a daily basis. Identifying underpayments and then adjudicating them with each of your payors can be a daunting process. In fact, it is estimated that the average medical practice loses as much as 11% of its revenue due to underpayments each year. Monitoring and appealing expected payments doesn’t have to be overly complicated or expensive IF you have the right resource or partner working on your behalf. The revenue generated from the underpayments will more than cover the cost and result in a significant gain overall.   

Join Our Newsletter

Get Updates Direct to Your Inbox. Gain access to a rich library of articles, white papers, webinars, podcasts and more. Register today to receive eMDs Insights newsletter.

*
*
*
*
Specialty *
State *