Urology Coding Alert

Getting glimpses of the payer experience is a good first step.

Though healthcare providers might not be enthusiastic about enhancing their relationships with payers, it’s essential to prioritize effective communication, and even teamwork, for establishing a beneficial working relationship.

In a recent webinar, Stephanie M Sjogren, COC, CPC, CDEO, CPMA, CPC-I, director of medical coding and provider reimbursement on the payment integrity team for ConnectiCare in Farmington, Connecticut, offered details about ways to improve the payer-provider relationship.

Sjogren’s insights are well worth understanding, as her experience extends to both sides of this relationship. Prior to working on the payer side, she performed medical record audits and provider education at a women’s healthcare group.

Here’s what she had to say.

Know That Payers Face Challenges, too

Providers and payers may see each other as adversaries in business, even though they rely on each other. Understanding the specifics of what each side is facing is key.

Provider challenges: Even though providers’ top priority is excellent patient care, they also want to get paid. However, reimbursement — in the correct amount or on time — is increasingly difficult for providers to secure. Guidelines, financial rules, and payer reimbursement practices keep changing, and it can be hard to stay on top of the updates.

“Navigating the complex system of public regulations and private business decisions places primary care physicians in a situation that is increasingly burdensome, overwhelming, and a significant source of physician burnout,” said Kent Moore, senior manager of payment strategies at the American Academy of Family Physicians. “As a result of this system, practices experience increasing operating costs, and physicians have less time for meaningful patient interactions,” adds Moore.

Payers may resort to claim denials and slow processing to control reimbursement, Sjogren said. “Providers can easily lose revenue because they don’t have the time, personnel, or expertise to adequately follow up on the missing documentation or appeal claims, especially if you’re a small office,” she said.

Payer challenges: “Improper spending is an enormous problem in healthcare,” Sjogren said. It’s such a huge issue that insurers are forced to act strategically to avoid serious financial losses. Remember that when insurers experience huge losses, healthcare premiums might rise, which means a potentially greater financial burden for patients.

Data from the Centers for Medicare & Medicaid Services (CMS) and National Health Care Anti-Fraud Association says that Americans spent more than $4 trillion on healthcare in 2020. The staggering part of this figure is not the total; an estimated $1.2 trillion is attributed to waste or abuse that represents unnecessary charges. “That’s about 25 percent of the services in which a payer pays for something that shouldn’t be paid or shouldn’t have been performed,” Sjogren said.

Often, these incorrect payments can be traced back to incorrect coding.

Be Specific With Payer Policies

Understanding the payer contracts is vital, especially if you have the opportunity to negotiate any terms and want to do so. The contract outlines the payment rates for services, and without full understanding, it’s hard to manage financial expectations. During the contracting process, request specific CPT^® codes, revenue codes, and HCPCS Level III codes, when appropriate. “Don’t be afraid to advocate for non-standard language,” said Sjogren.

If there is language in the contract you don’t understand, simply ask about it. After all, failure to comply with the terms of the agreement could result in penalties or even the loss of the contract. In terms of patient care, the contract dictates limitations, such as when pre-authorizations are required and so on. If any of these items are unclear, ask the payer to clarify and provide examples.