Last Updated: Oct 12, 2023

You can’t look at your LinkedIn feed or industry articles without seeing something about payers in today’s market. Either they are recording large profit margins or getting into hot water for violating contract agreements regarding reimbursement rates.

As providers, we depend on fair and adequate reimbursement based on our contracts. Yet with each contract review, we consistently find where those agreed upon rates have fallen by the wayside. Practices are losing out on the revenue they are owed. Fee schedule rates continue to decline, and denials pile up due to the lack of experienced staff and length of time needed to adequately resolve the denials.

What Can We Do?

• Know your contracts! Contracts are signed and filed away – in some cases they are 10+ years old! Compare the rates to what is currently being paid. If the payer is working from the MPFS, make sure they have updated their fee schedule yearly as Medicare does. Check if they have agreed to pay a percentage or dollar amount over the fee schedule. A quick check of the contracted rates may reveal it’s time to renegotiate or discuss missed revenue.
• Know your payer rules up front and strive to keep the coding team informed of policy updates or changes. Payers update policies regularly so if possible, have someone on the coding team dedicated to checking these policies at least yearly. Stay ahead of any potential denials related to medical necessity or a policy change.

Simple process changes can save your practice thousands of dollars in missed revenue. Strive to keep your coding team ahead of the curve with continuing education, webinars, and conferences so they have the latest and most updated information for your specialty. As providers, take time to listen and understand documentation requirements for the services rendered. We know you do the work – we just want you to document it all!

With payers recording revenues in the billions, practices must stay vigilant to their reimbursement policies both publicly and contracted. Strengthening the knowledge of the providers and the coding team will help to circumvent those pesky medical necessity denials (and others). Contract reviews for commercial payers will ensure practices are being reimbursed fairly and appropriately.

At Granite GRC, we have a team of seasoned reimbursement professionals who love delving into revenue cycle concerns. Whether it’s denials management, process investigation, or auditing needs, we are available and willing to bring our expertise to help!

Crystal Stalter, CPC, CCS-P, CDIP, CCDS-O

Director, Revenue Cycle Assessment and Compliance