An associate of mine at primeCLAIMS, recently related a turn of phrase that I agree can apply to working with managed care organizations (MCOs), “If you’ve seen one contract, you’ve seen one contract.” Depending on the number of managed care organizations your company or facility works with, billing the right payer and submitting the correct claim with the correct information can be quite complicated. MCOs have parallel as well as divergent policies for correct claims submission. Knowing what those contractual requirements are and fulfilling those requirements is the key. So, how does a biller keep this as simple as possible?
What’s in each contract – knowing what is covered, not covered
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:
- Levels of care by RUG scores or service levels, which specific diagnosis codes are allowed, how many days are considered co-pay days, which ancillaries are covered in the base rate and which may be billed separately or not at all, if a pre-authorization and re-authorizations for a stay is needed, and so forth. Most will agree that no two MCOs are alike. Knowing what services and procedures are covered is essential to and getting paid at the proper pay rates without unnecessary delays.
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.
What’s in each contract – knowing how to complete the claim form
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.
Keeping it all in one place – a ready reference
Wikis are everywhere on the internet these days. Our support teams use wikis to have a ready reference when assisting our customers with questions they may have or to help them troubleshoot an issue they may be dealing with. So, why not create a hard copy MCO contract wiki? 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.
Set up the system correctly the first time
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.
Keeping the managed care billing process can easier to manage if providers will:
- Set up a binder or book in which to keep each contract and its summary/cover sheet. All billers need to become familiar with each contract.
- Correctly set up the contract provisions within the billing software.
- Refer to the contract summary sheets during the triple check process.
One More Last Word
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.
 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.
 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.