Setting up contracts and payers: How to get the most out of your software to maximize IV collections
By: Brenda Langlais, Reimbursement Manager, Mediware Reimbursement Services
When billing for home infusion services, it can be difficult to properly bill and send clean claims every time, but relying on your software can lessen the burden. Many providers are doomed from the start, as they don’t take the time to properly set up contracts and payers in their systems. Most software has some level of capability to assist in streamlining the billing process. Loading contract fees and terms can help to capture all of the revenue you are entitled to receive by: billing ALL items that should be billable; ensuring accurate booking of net revenue while still billing the claims at gross; and alerting the billing staff to which items require authorizations. Without taking advantage of the software automation, the billing department becomes responsible for remembering all of these critical tasks and other various terms of the contract. Below are a few tips on how your pharmacy can take advantage of your current software system’s capabilities to ensure clean, accurate, and error-free claims.
Maximize home infusion collections with Mediware Reimbursement Services!
Understand your contract and payer terms
Many billing specialists never actually see the contracts themselves, which results in improper billing and inaccurate claims. To ensure an understanding of contract specifics, provide your billing staff with a copy of all contracts before entering the details into your software system. This will help your team send accurate claims while eliminating guesswork. Comprehensive knowledge of your contract terms will also help you intelligently respond to a payer if claims are overpaid, underpaid, or denied entirely. Remember it is equal work to resolve a claim if you are overpaid or underpaid. Knowing the terms of the contract gives you the basis for your decision and ‘next steps’ regarding the claim payment.
Map your contract and payer terms to your software system
Once you know your contract terms, enter them into your software system to help safeguard your billing process against inaccuracies. This way, every billing specialist can refer to the system if questions arise on payer requirements for any given claim. Because this step takes a lot of time and requires a degree of understanding of a system’s intricacies, many providers simply skip it. Unfortunately, this leads to inconsistent and incorrect claims being produced, careless errors resulting in denials; and improper payments. Information to enter includes:
● Pricing model: the payer’s specific pricing model (a derivative of AWP, ASP, WAC, etc. or even a fixed fee rate.)
● Timely filing guidelines: the payer’s specific guidelines for when initial claims and appealed claims need to be submitted.
● Authorizations: which items or item categories require authorizations prior to billing and is the authorization written or verbal
● Billable vs. non-billable items: what is included in a per diem and what can be billed separately (infusion pumps, elastomeric disposable pumps, saline, heparin, etc.)
● Additional documentation requirements: CMN, DWO, desk script, medical records, patient authorization, single case agreements, etc.
Challenge your payers and empower billers
After the information is correctly entered into the system, your billing staff can rely on it to reduce human error. If a payer mistakenly issues a denial or underpayment, the billing team must be able to easily access the contract information which will help them determine if an appeal is necessary. Your contract is the support you need to fight for the money you are owed!
When your organization receives an overpayment, your billing staff can review the terms and issue the proper refund or initiate a payer takeback. Failure to do so can put you at risk of future recoupment and/or a possible audit. Whether you’re correcting overpayment or underpayment, take the time to understand why the inaccurate bill was issued so you can proactively rectify future errors.
As home infusion reimbursement margins continue to shrink, providers must streamline their billing processes. Effectively using your software technology to maximize collections is essential to your organization’s survival. Failure to take full advantage of the software could result in unnecessary loss of revenue. If your pharmacy needs assistance with billing home infusion supplies and services, Mediware Reimbursement Services provides consulting, collection assistance, and full outsourcing to ensure your pharmacy collects everything it’s owed.