In a traditional healthcare setting, the revenue cycle begins with the insurance companies who pay the majority of the bill. There are multitudes of payers and each payer can have many plans. How can a healthcare organization catalog this information, keep this information updated and make this information easily accessible to staff so they can discuss payments with patients in an informed and confident way?
Start by breaking your payers into five main categories as a logical way to organize the data.
- Payers with whom you have a contract
- Payers with whom you do not have a contract
- State and Federal government payers (Medicare, Medicaid, TriCare)
- Medicare Advantage payers
Payers with whom you have a contract
Your organization has signed a contract with a payer and you have agreed to accept a discounted fee called an allowable, and to abide by their rules. What is the information you need to collect?
- A copy of the contract
- A detailed fee schedule, or a basis for the fees, such as “150% of the 2008 Medicare fee schedule.”
- Any information about the fees being increased periodically based on economic indicators, or rules (notification, timeline, appeals) on how the payer can change the fee schedule.
- The process and a contact name for appealing incorrect payments.
- Information on what can be collected at time of service. Hopefully your contract does not have any language that prohibits collections at time of service, but you must know what the contract states.
- Process for checking on patients’ eligibility and benefits: representative by phone, interactive voice response (IVR), website or third-party access.