As Medicare reimbursement cuts continue agencies will be forced to expand into the managed care and private insurance markets. Doing so is a complicated process that involves contracting, intake process changes, staff education, and billing and collections complexities not seen with Medicare. Part one of a three part series, Managing the Managed Care and Insurance Maze, will focus on the importance of the contracting and credentialing process.

Typically, the process begins with a request to become a credentialed provider. The insurance company will ask for licensing and insurance information and an application will need to be completed. Next you will receive a proposal from the payer. During this process, develop a relationship with your contract representative because you will need them in the future. Remember, they are selling a product. It is during this process that the insurance company will be most willing to communicate and educate. Review the proposal in detail, ask questions and get those answers in writing. Save all email correspondence related to the credentialing process. So many times, an agency will go right to the reimbursement rates page and make their acceptance decision based entirely upon what they will be paid per visit. The devil is in the details so this is much more complicated than the expected reimbursement rate per visit. Does the proposal answer the following ten questions in a clear and easy to understand manner?

  • How tedious and time consuming is the authorization process?
  • Are medical supplies reimbursed?
  • What are your appeal rights and what is the appeal process if claims are denied?
  • How long do you have to file a claim?
  • What is the term of the contract and how do you get out of it if it isn’t working for you?
  • Which plans are covered by this agreement and more importantly, which aren’t?
  • Is there a provider manual available?
  • Are there on-line resources available for eligibility verifications and billing inquiries?
  • What prompt payment commitment does the payer make in the agreement?
  • Are premiums paid for complex visits such as SOC, Eval, or infusion visits?

Get your billing department involved in the contract proposal review process early on. Have your billing manager or out sourced billing company review the billing language in the proposal and make sure they understand the specifics.

If you decide to sign the agreement, the work is just beginning.

Use the following checklist to ensure success:

  • Take advantage of all available educational resources that the payer provides.
  • Get access for your staff to web-based tools for eligibility verifications, notifications, and billing inquiries.
  • Educate the intake staff and marketers on the specific plans covered under your contract with the payer
  • Walk through the eligibility verification process with your intake staff. Make sure they understand the process.
  • Educate your administrator on the payer specific authorization process.
  • Have the billing manager read and understand the billing specifics in the provider manual.

Exhausting right? We aren’t even close to done yet. The next two articles in this three part series will focus on managing authorizations and lastly, billing and collections.