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Know, Understand, and Continually Monitor Payer Contracts

Written by: Mediware Bloggers on Monday, March 20, 2017 Posted in: HME/DME, Home Infusion

By: Kathy Wright, Reimbursement Manager, Mediware Reimbursement Services

Like any kind of contract, the terms of which govern the relationships between the contracted parties, your contracts with payers are your billing team’s guideposts to payment. Therefore, your team needs to comprehend the details of every contract, which vary by payer, so that every bill you submit is in compliance with the terms. Compliant claims are your insurance for getting paid.

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In home infusion billing and collections—among the most complex of any healthcare reimbursement—an in-depth knowledge of the details is especially important, but it’s also difficult to achieve. I recommend that your billing team start with a careful examination of the wording of each contract, during which they are looking for details about:

  • What is included in kits and excluded from kits
  • Other specific inclusions and exclusions
  • Special coding or modifiers (may be unique to each payer)
  • Per diems
  • Timely filing limits (how much time is allowed to get a clean claim on file as well as time for appeals)

Other details to watch for include nursing visit requirements, which could be billed separately or included in the per diem, and limitations on supplies. In addition, billing staff need to be aware of how each payer wants to be charged for all the different products—whether units, milliliters, vial size, cans, etc.—as well as requirements for equipment and maintenance, such as when it can be replaced and how often, for example.

Without thorough knowledge of all of these details, it’s likely that your claims will include errors, and those inevitably lead to denials. However, even if you do eventually gain a thorough understanding, there’s a good chance that, at some point, something will change, so staying on top of payer contracts is an ongoing process.

Fee schedules are especially likely to fluctuate, possibly even from month to month, so billers need to stay aware of changes. They should also monitor reimbursements to catch errors.

By proactively managing your contracts, rather than reading through them after denials, your billing team can avoid revising and resubmitting claims. This means you not only operate more efficiently, you can be paid more quickly. However, if your home infusion business continues to struggle with understanding contracts and billing accordingly, contact the expert infusion billing team at Mediware Reimbursement Services.

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