Providers vs. Payers: Collaboration is the Best Medicine

Providers vs. Payers: Collaboration is the Best Medicine

Work together to get claims payment issues resolved.

If you are a coder who works for a large payer organization, your day-to-day work looks different than that of a coder working for a provider. I’ve worked for both the provider and payer sides, and I’ve been on both sides of a medical record request. It’s no fun for anyone. To come to a favorable resolution, it’s important to understand how to navigate these scenarios and to see the payer’s point of view.

Roles on Both Sides of the Fence

Provider coders — whether physician, facility, or ancillary (such as home health, lab, ambulance, etc.) — translate what the provider has documented in the patient record into a claim that will be paid by a third party or payer. Challenges for provider coders include everything from meeting productivity quotas, to managing the revenue cycle, and more.

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Payer coders have a completely different experience. The coding (and clinical) staff isn’t able to speak face to face with the provider submitting claims because, rather than working with a few providers, the staff is working with thousands of them. The provider’s submission (the claim and subsequent documentation) is all that is available for basing decisions regarding reimbursement, review, denial, or recoupment.

Medical Records Request

Payers requesting medical records for claims that have already been paid typically send a letter to the provider’s correspondence address. The letter generally dictates what types of records are needed (e.g., lab reports, radiology reports, etc.). If the request involves supplies or durable medical equipment, a proof of delivery, Certificate of Medical Necessity, written order, etc., are necessary. Requests for claims that are pending or held prior to payment for review usually are part of the provider remittance advice (PRA). A letter could also be generated for prior-to-payment requests.

Payers can also use vendors to perform reviews. Vendors must sign a business associate agreement with the payer if they are performing a review. A letter disclosing this agreement may be sent to the provider just prior to a request for medical records. This announcement letter usually requires no action on the part of the provider unless it is accompanied by an actual request for specific patient records. Receipt of an announcement letter does not mean the provider has been targeted for the review — only that the provider falls within the scope of claims or providers eligible for review.

If you receive a request from a payer for a patient’s medical records, it’s usually in response to:

  • A general review for all providers claiming a particular service or combination of services/diagnosis(es)
  • A review for certain providers based on peer-to-peer performance (higher utilization of a particular code when reviewed next to claims from peers of the same specialty)
  • A review of all providers under a particular tax identification number (TIN) based an external request (such as from the Centers for Medicare & Medicaid Services (CMS), Office of Inspector General (OIG), or a state agency)
  • A review of a certain provider based on an external request (such as CMS, OIG, state agency, or member appeal)

There are other reasons for medical record reviews, but this list covers 99 percent of requests. Reviews may be performed either prior to payment or after payment has been made, depending on the contract language between the provider and the payer (if a contract exists). Contracts between providers and payers generally specify the length of time in which reviews (prior to payment and after) can take place, as well as other stipulations. If there is no contract, the review time frame in a particular scenario is at the payer’s discretion.

What to Do when Requests Are Received

Payers have an address to which payments are sent, and sometimes a different address for correspondence. When a request for medical records has been issued (either by letter or PRA), the time clock starts for the payer to receive the documentation. Payers typically reach out to providers after certain time markers to ensure requested documents have been received to avoid a denial based on non-receipt of records.

A common complaint payers hear from providers is that the letter/PRA in which the request is made gets transferred from department to department so by the time the right person gets the request, it’s too late and the denial for non-receipt has happened. Payers strive to have the right mailing addresses, but with thousands of providers of all types throughout the country, this can be a daunting task.

When a request is received, the provider’s team should:

  • Check the date of the letter. If it’s more than a month old, chances are it has traveled from department to department.
  • If you are responsible for sending the requested documentation, contact the payer by phone or email using the information on the letter and explain the situation. Any contact by the provider generally will prolong or restart the time frame for receipt. Find out the payer’s specific protocols for documentation receipt. Payers want to work with providers; they don’t only want to deny claims.
  • If you are not the correct person to respond to a documentation request, and depending on your directives from your leadership, make sure it gets to the right person. When the responsible person receives the request, they should contact the payer immediately, as above.
  • When contacting the payer, request additions or changes to the address (such as an attention line, etc.) to avoid future issues.
  • Review the type of documentation requested, and send those documents. Completeness and legibility of documentation is paramount. Incomplete records, or records that cannot be read, are of no use to reviewers trying to determine whether services billed as rendered meet the necessary documentation requirements. For example: For evaluation and management codes, if there isn’t a clearly defined review of systems, but the history and medical decision-making are clear, the service could be either denied or recouped based on lack of documentation.
  • Contact the payer with questions using the information on the request, as necessary.

Relevance matters: Do not send a 400-page record unless every page is pertinent to the request. Keep in mind that a fellow coder likely will be responsible to decipher the material (at least at first). Sending records with random pages upside down, multiple pages containing only a single sentence, or records that are not pertinent to the request causes extra work for the person receiving the documentation, who did not put the review in place. There’s no reason to shoot the messenger.

If you’ve missed the deadline, and the claim is either fully denied or is in the process of recoupment due to non-receipt of documentation, contact the payer immediately. Many payers are happy to review the documentation, and may reverse the denial or recoupment without resubmission of the claim if the submitted documentation meets necessary criteria.

The payer will have multiple avenues to receive documentation, such as postal services, secure fax, secure email, and in some cases a secure FTP site for quick transfer. Whichever method you choose, follow up to ensure the payer received the documentation.

After the Documentation Is Submitted

Upon receipt of the requested records, the payer clinical team begins to review the documentation. It takes time to ensure the entire claim case is reviewed. Sometimes the payer clinical team may ask for clarification of documentation or additional documentation if it appears something is missing. The payer clinical team makes multiple efforts to reimburse the provider, rather than to pursue denial or recoupment. But it’s common not to receive feedback if the documentation sent substantiates the service billed (i.e., no news is good news).

If every attempt is made to substantiate the service using the documentation submitted, but it cannot be reconciled (and depending on the scope of the review), a denial or recoupment takes place. This could mean the entire claim is denied/recouped, or only a line item from the claim.

Typically, a letter is sent with the review outcome (the findings letter) that narrates the reasons why the payer feels the documentation does not support the claim as billed. Every provider has some level of reconsideration and appeal rights; check with the payer as to what they offer if you disagree regarding the findings. Usually, instruction is given in the letter as to reconsideration and/or appeal. Providers who are contracted with the payer often have a “provider advocate” assigned to their group; you may contact this advocate at any time for questions regarding correspondence from the payer. Communication with the payer is important because, although payers are similar, each has its own specific procedures for each step in the process.

Payers, like providers, are an important piece of the healthcare puzzle. Together, we can reach a favorable outcome.

Susanne Myler, COC, has more than 25 years’ experience in the healthcare industry from claims biller to executive management. She attended Stephen F. Austin State University in Nacogdoches, Texas, and is employed by a large healthcare payer organization. Myler is a member of the Abilene, Texas, local chapter.


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