The devil is in the details. And since each MCO contract may be different from the others, billers should understand what’s in each. The contracts may specify:
Caution: Billers need to be mindful that facilities may admit a resident/patient who is to be covered by managed care, but with whom the provider does not yet have a contract. In that event, the provider may not receive full pay for services rendered since the MCO in question may consider the claim out-of-network.
Billers need to have a working knowledge of what each MCO expects to have included in the claim form as stipulated in each contract. We recommend that billers have access to the contracts and to know what each requires. Our Managed Care Master App can help.
We advise all providers to compile all of their managed care contracts into one location, perhaps a tickler file, a file drawer with a folder for each contract, or a binder. In front of each contract, providers should place a completed summary form highlighting what each payer will pay for under what circumstances using which codes, paying how often. Each summary sheet highlights the essentials that must be included in each claim and should serve as a reference tool during the triple-check meeting. Or better, if you don't want to physically maintain contracts, check out our Managed Care MASTER app for housing your contracts online with easy-to-reference contract summaries.
Another best practice to help simplify the process is to set up each contract’s claims requirements within the billing software, such as rates, included and excluded diagnosis codes, etc. Word to the wise - Take the time now to set it up properly or deal with possible problems later[2].
The managed care billing process can be easier to manage if providers will:
My primeCLAIMS colleague, Mike Giel, suggested we mention that in the contract negotiation period, providers need to discuss what provider enrollment procedures the MCO requires before claims can be submitted electronically. Think of it this way. The contract is the key to opening the claims flow door. The enrollment form opens the door. Completing, submitting, and receiving approval prior to submitting the first claim will ensure that the door is open and remains open so that claims can go and payments come in unhindered.
It just makes good cents.
[1] Example: Pre-authorizations are usually required to pre-approve a specific length of stay. Providers may need to get authorization to extend the stays beyond the initial authorized period. If providers don’t secure a reauthorization, they will have to worry about who will pay for the rest of the stay. Knowing that in advance can eliminate frustrations for all involved: the resident, the resident family, and the provider.
[2] Note: Contracts have a life of their own and can change over time. When those changes occur, record them in the contact binder and billing software set up.