Negotiating Justifiable Contract with Health Insurance Companies

Care providers operate in an environment characterized by multiple payors – Medicare, Medicaid, and a host of private health plans. The prevalence of such multi-payer is reason enough for differences in rates at which care providers are reimbursed despite the clinical procedures more or less being the same. Adding to this heterogeneous payor-environment is the regional differences wherein a physician practicing in an urban state gets reimbursed more than its counterpart in a rural state.  Are we simply to believe that these are irreversible factors, and physicians are left with no avenues but to accept what is offered?

Certainly, multi-payor system and regional factors should never hold you from claiming what you really deserve. If you happen to be as good a care provider as your counterpart in a metropolis, you are entitled to be reimbursed on par with the best rates. This is where your negotiation skills come into the fore – convincing you’re your payors as to why they should reimburse you at the rates given in the fee schedule, equivalent to the CPT codes, and to the maximum extent possible.

The extent to which you can negotiate is often decided by your being in a particular network – HMO or PPO. If you are a HMO provider, your negotiation is limited to Medicare or Medicaid fee schedule.  Medicare, being public plan, reimburses you at a rate which is comparatively less than a physician gets by being a provider in PPO. At best you can insist on getting reimbursed on par with what the admissible CPTs deserve.  But, to insist on being paid at CPT-equated level, you will certainly need to back up with clinical and quality credentials – care excellence, EHR implementation, and compliant coding and billing practices.

Browse All: Medical Billing Services

If you happen to PPO provider, being supported mostly by private carriers, can expect variable and maximum scope for negotiation – by being in the PPO network, you can expect to be paid at rates higher than in Medicare fee schedule.  But your payors are not going to be convinced unless you support you claim with valid reasons and proof. Amongst many ways through which you can negotiate better deals with your payors are:

• Keeping track of history of your claim submission and eventual realization:
This will provide with variance in your expectation and eventual pay out. When such variance are brought to the notice of your contracted payors, payors may be inclined to have a relook at the existing reimbursements, and may even amend with higher rates.

• Being aware of the rates offered by other plans:
This will help you compare your reimbursements with what your counterparts in the similar field are paid by other plans elsewhere. When these differential rates are brought to your payors notice, they may be inclined to revise to higher rates provided your quality of health care is as good as it is elsewhere.

• Being aware of geographic advantage:
If you happen to practice in an area that distinctively know for medical care quality, you try to force this into your advantage; payors are generally convinced of relatively higher level of quality care in urban and metropolis.

• By threatening to walk out temporarily:
If your payor is not open to the idea of negotiating, you may consider coming out of the contract. And when you start billing 100% to your patients, patients in turn may switch sides to payors that offer maximum coverage. This may force your original payor reconsider his original stance.

All these seemingly possible tactics would have to be carefully implemented. Care providers, who are primarily focused on clinical job, may be found wanting tactically. This is where medical billers would be sorely required. Medicalbillersandcoders.com – with a thorough understanding of multi-payer reimbursement environment – continues to mediate justifiable contract with health insurance companies across the 50 states in the U.S. Irrespective of your being HMO or PPO, our expert team of insurance contract negotiation is essentially driven by the motto: “maximizing your reimbursements”.

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies in USA & help doctors to shortlist Medical Billing Companies, Medical Billing Services according to their preferences of specialty, city, software and services performed.

What makes Outsourced DME Billing Superior?

Physicians who are part of DME services now face an important operational decision: whether to persist with in-house billing staff or entrust to external sources. The long-held belief that in-house billing staff would manage DME-related billing complexities seems to have failed them recently – most of the in-house-staff-managed DME billing are reported to have high incidence denial, delay, or under realization of DME bills from Medicare, Medicaid, and private DME health plans.  And, now that physicians strongly feel the reason to replace in-house DME billing, should they be embracing outsourced DME billing straight away? Yes, but not before they have debated pros and cons of DME billing outsourcing.

Arguments in favor of DME Billing Outsourcing

Primary argument in favor of outsourcing DME billing is that it will bring a fresh perspective to hitherto stereotype practices – outsourced DME billing providers, with their specialization, could iron out deficiencies, and improve realization. The in-house staff, on their part, will be able to concentrate on clinical priorities, and prepare reliable data for DME billing and coding.

Second, care providers need not worry about capital investment associated with training people and installing system for DME billing; an outsourced service comes with a ready-combination of trained people and systems. Moreover, with a large clientele, it will be easy for your prospective service provider to pass on the economies of scale.

Third, outsourced DME billing providers are supposed to have good terms with payers and agencies. Their being well-acquainted with Medicaid, Medicare, and private health plans should help care providers in knowing, negotiating, and responding better to dynamics of DME billing. Likewise, DME billing providers can save you from accepting health plans that are either operationally non-profitable or non-supportive of DME services.

Last but not the least, DME billing providers can be relied upon to keep A/R days within the permissible limit – with supposedly superior expertise in ICD and HCPCS coding, there should be little need for Decreased denials and/or front end rejections: as a result of expertise in ICD-9 and HCPCS coding, for re-filing, rebilling or appeal.

Arguments against DME Billing Outsourcing

Primary argument against outsourcing DME billing is that it involves lot of deliberation while selecting a prospective service provider from so many operating in the market – the chosen provider may or may not turn out to be a suitable one; sometimes, it may turn out to be inferior to your in-house DME billing.

Second, outsourced DME billing may initially need to be synchronized with your operational environment. And, when DME billing needs to be customized to your requirement, there will be likelihood of DME billing cost being escalated.

Last, mobility may sometimes be an issue – your outsourced DME billing provider may not be logistically near your clinical facility. Therefore, there could be considerable time gap between what you need and what you eventually get from your DME biller.

Because pros outnumber cons, physicians should consider it operationally viable and profitable to entrust their DME billing to outside service provider. With operational burden taken out of their minds, they can focus on clinical priorities, which essentially decide their competitiveness. Medicalbillersandcoders.com has veritable success as leading DME billing service provider; a great majority of care providers across 50 states in the U.S. have benefited from our specialized, economical, and collaborative DME billing services. And, as the demand for outsourced DME billing services is likely to increase in coming days, we hope to leverage on our nationwide DME billing specialists in bringing you operationally profitable billing solutions.

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies in USA & help doctors to shortlist Medical Billing Companies, Medical Billing Services according to their preferences of specialty, city, software and services performed.

Challenges and Opportunities of Durable Medical Equipment Practice (DME)

The necessity of Durable Medical Equipments (DMEs) had never been so high – in U.S. 30% to 54% of those over 65 years have some form of disability; around 75% to 90% of such disabled require some form of DME to keep them mobile or enabled. It is also estimated that around 1.5 million people are currently in need of wheelchairs and braces. And, when you add the population that is likely to be in need of other forms of durable medical equipment – prosthetics, orthotics, and supplies (DMEPOS) – it will be some opportunity to people involved in Durable Medical Equipment services: physicians, pharmacies, and manufacturers/suppliers. But, because DME services are physician-recommended, we are more interested in how physicians themselves can recommend, source, and administer DMEs.

While physicians can benefit immensely from an integrated DME management, there are challenges on way – being equipped with a Medicare enrolled and recognized pharmacy, sourcing supplies from bidders authorized by CMS, and showing up as participating supplier, who accept Medicare approved fees on DMEs.

Physicians who are willing to have pharmacies attached with Medicare Part B approval need to have a full-pledged Medicare Part B recognized DME supplies. The importance of having Medicare approved DMEs at your pharmacy is that it enables patients to have access to DMEs that are fully covered and reimbursed from Medicare Part B.

DMEs cannot be freely traded at your pharmacy; you need to apply for authorization from CMS. First, you need to apply by filling up Form CMS-855S for all likely suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). Applications are verified by National Supplier Clearinghouse (NSC) before being certified for compliance with DMEPOS Supplier Standards, as set forth in 42 CFR 424.57

Physicians in DME services are expected to be responsible – being responsible means agreeing to accept Medicare-approved amount as full payment. Physicians that accept this clause will stand to collect only 20% of the approved amount after the patient has paid the part B deductible. Though not mandatory, being partner in sharing monetary responsibility may have disguised benefits, such as goodwill and patient-initiated referrals.

While suppliers recognized by CMS are generally dependable, there have also been cases of sub-standard supplies. Accepting any supplies without thorough inspection may prove to be clinically inapt or underperforming. Therefore, physicians from time to time need to verify suppliers’ credentials and report cards as and when they are published by CMS.

Notwithstanding these possible challenges ahead, physicians in DME services should have ample scope for revenue generation. Consider the scenario when Medicare will be extended to every U.S. citizen – with a majority of current Medicare beneficiaries yet to utilize DME benefits, DME practice itself will be a major attraction amongst practitioners. And, with strategic partnership with medical billing providers, physicians can expect to overcome these incumbent challenges, and become more than being just survivors.

Medicalbillersandcoders.com has always responded positively to every clinical and operational challenge. Whether it is billing and coding, EHR implementation, or ICD-10 transition, we have been the first to assume responsibility. Medical practices of varied sizes and disciplines across the 50 states in the U.S. would readily endorse us as most dynamic and comprehensive source for overcoming clinical and operational challenges. And, at a time when DME practitioners find themselves in between opportunities and challenges, we are hopeful of helping them overcome challenges and realize opportunities.

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies in USA & help doctors to shortlist Medical Billing Companies, Medical Billing Services according to their preferences of specialty, city, software and services performed.

Overcoming DME Billing Challenges with a Medical Billing Service

There is a distinctive difference between billing for Durable Medical Equipment (DME) services and other clinical procedures – durable medical equipment services are ancillary to the primary clinical purpose, and their admissibility is subject to certain conditions.  Physicians since long have found these conditions tricky and challenging to understand, and often either been denied or underpaid for DME services, which may either have been

• Deemed medical unnecessary,
• Uncertified by Medicare/Medicaid/private health insurers,
• Beyond the permissible reimbursement level
• Lack of solid grounding in the Healthcare Common Procedure Coding System (HCPCS), which governs level II codes designated for DME equipment and supplies

While physicians have the right to recommend DMEs as part of a clinical treatment, they will have to back their recommendation with sufficient proof of them being medical necessary. Proving medical necessary alone will not suffice; it is equally important to know whether or not patient’s health insurance coverage supports DME services. With Medicare, Medicaid, and even certain private insurance schemes cautious about supporting exorbitant DMEs, physicians would do well to be verify whether or not patients’ health plans support DMEs.

Reimbursements are subject to the condition that physicians or patients source the admissible DMEs from payer-recognized vendors or manufacturers. While this condition may endorse payers’ commitment toward quality DMEs that last long and are competitively priced, physicians will certainly be put through the process of identifying Medicare/Medicaid/private insurer recognized vendors or manufacturers.  What is more interesting is that Medicare has designated certain pharmacies that can only supply admissible DMEs. Therefore, physicians’ task of identifying and sourcing DMEs has certainly become more complex than ever.

DMEs have grown to be clinically superior and functionally perfect these days. While appreciation in quality has facilitated clinical efficiency and patient well-being, price has been a major issue. Payers have not been all that receptive to the idea of supporting DMEs that are not operationally viable. Medicare/Medicaid too has its own reservations against highly-priced DMEs, and has put a ceiling on DMEs reimbursements.  Physicians, therefore, need to be aware of these restrictions while encountering patients that require DMEs well beyond their insurance eligibility.

Lack of solid grounding in the Healthcare Common Procedure Coding System (HCPCS), which governs level II codes designated for DME equipment and supplies, has largely been responsible for physicians’ below par realization of DME bills. In fact, if we revisit payer reports, wrong codes, absence of modifiers and insufficient narration seem to have contributed to drastic fall in reimbursement of DME bills. With care providers transiting to a more streamlined coding practice in ICD-10, DME-relevant codes will further get emphasized.

But for physicians, who are already reeling under a series of health care reforms, DME-related challenges may prove to be simply unbearable.  In-house staff, who are generally tied with clinical duties, may not be able to stretch beyond their general billing capability. The situation prompts an external medical billing intervention that can offer DME billing as part its comprehensive medical billing services.

Medicalbillersandcoders.com has verifiable success in DME billing services for practices across the 50 states in the U.S. The experience of negotiating DME claims with state-specific Medicaid policies, Medicare, and a host of private health plans is itself proof of our competence. With a team of DME billing experts at your service, challenges associated with ascertaining DME necessity, Medicare/Medicaid/private health insurers’ approval, permissible reimbursement level, and Healthcare Common Procedure Coding System (HCPCS) might just be the thing of the past!

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies in USA & help doctors to shortlist Medical Billing Companies, Medical Billing Services according to their preferences of specialty, city, software and services performed.

Managing Holiday Season Resource-Crunch with the Help of a Medical Billing Company

Healthcare is perhaps one of those few professions which are exception to the general rule of eight hour-a-day duty – professionals are required to stretch beyond their usual duty hours, and may even have to be on a 24×7 vigil. As a result work-related fatigue has been more common, which is undesirable from clinical point of view. Fortunately, holidays offer welcome-break from the rigors of work, and help professionals revitalize their mind and body. Generally, holidays in U.S. are season-driven – most professionals opt for holidays during Christmas.

While professionals can look forward to a long-awaited break this Christmas season, there is something whose rhythm cannot simply be ignored – medical billing, processing and claim realization. But, when the majority of resources – either internal staff or external resources – are expected to be on leave for a considerable period,  a large portion of medical practitioners’ bills may remain unprocessed, unrealized or piled up as account receivables, which are potentially detrimental to financially viable clinical operations.

During such resource-crunch times, medical billing companies – with enormous, flexible and agile resource base – should keep your reimbursements unaffected. While you may have conceded to the idea of outsourcing from medical billing company, you should still arrive upon the best source among many billing companies offering their services. The following factors should help you determine whether or not the medical billing company in question is credible and competent enough to fit into your requirements:

Is the company open to the idea of risk-sharing? Many companies are open to the idea of operating on a risk-sharing model – being able to share operational profit or loss equally with their clients, i.e. medical practitioners. Therefore, it is better your prospective medical billing company is comfortable with this clause.

Will the billing company earmark a separate account representative? Medical billing company manages many portfolios, and a single-contact may not be able to answer queries from multiple clients. Therefore, it is better to know if your prospective medical billing company will be able to appoint an account representative exclusively to look after the affairs of your medical billing process.

Will your billing company pursue denials astutely? Denials if not pursued may end up as irrecoverable. Therefore, it is necessary to know in advance whether or not your prospective medical billing company is credited with astute denial management.

Will your filing be on time? Claim submission if not done on time may well get rejected. It is the responsibility of your medical billing company to keep you alerted about filing deadlines, and knowing that your prospective billing partner is sensitive to filing deadlines really helps.

Will my Practice Management be integrated with EHR? The success rate of reimbursement is often decided by how best your PMS is integrated with EHR system. Therefore, your prospective medical billing partner should be capable of implementing a single and integrated platform comprising both PMS as well as EHR.

Will it offer customization? Outsourcing an entire range of general solutions may not make sense – few processes may be irrelevant or may have to be customized to your billing needs. Therefore, it is crucial to know whether or not your prospective billing company can offer the right mix of services to your practice.

What about its success rate with A/Rs? The credibility and competence of a medically billing company is built around its ability to reduce its clients’ A/R days to permissible limit. Verify your prospective biller’s credentials in A/R management before entrusting your billing management.

Is it familiar with technology demands? Medical billing is increasingly being managed by technology – clinical documentation, billing, coding, claim submission, realization, and reporting are all serially managed over a well-networked real time computing. Therefore, it is important to know whether or not your prospective billing company is sufficiently equipped with these technology demands.

Medicalbillersandcoders.com – being the largest consortium for medical billing services – has demonstrated its worth as reliable, broad-based, and flexible medical billing partner for practices of varied sizes and disciplines. Our intense resource-deployment during times of resource-scarcity has helped practices to keep their reimbursements and revenues unaffected even during holiday season. As practices are about to enter another holiday season, we assure them of everything that they anticipate from an ideal billing partner.

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies in USA & help doctors to shortlist Medical Billing Companies, Medical Billing Services according to their preferences of specialty, city, software and services performed.