Monitoring Payor Contracts – Problems 101

How can we make your troubles go away?

Three common problems show up in managing & monitoring payor contracts at most health care facilities. In this blog, let me walk you through how to spot problems and find possible solutions.

Remember that line from the country song in the 90’s? Or maybe it just resonated with you because yep, you got trouble. Everybody does.

Long ago I learned that my clients come to me because they have a problem. If they could fix it themselves, they would. Sometimes it’s a problem they don’t want to fix and need someone from the outside to assess and come up with a solution. Coming from an external resource, the news is easier than from within.

Since my expertise is in the payor contracts area, let me talk about the troubles I usually find. I’ll try to make these as positive as I can, but they all are going to start with a “not” in the first sentence.

Trouble #1: Contracts not loaded into a contract management system. Only when you have the contracts broken down so they can match up to the data that applies to each contract term, can you calculate expected reimbursement and compare the expected reimbursement to the actual. And only then can you have automated tools to identify and track the trends of underpayments, denials, short pays, no pays and zero pays. Tracking these payment compliance issues will help you find the underlying causes whether those be in the charges, medical records coding of procedures and diagnoses, system setup, payor issues. People can only look for what they have tools to search with: without a shovel it is hard to dig a hole to find water; without a pickaxe it’s hard to chip away at a mountain to find gold. A contract management system provides the shovel and the pickaxe. If you don’t have one, there’s your trouble.

The fix: In order to load the contracts, you have to find them (paper), organize them and have someone to load the rules into software. Then you’ll need to set up the software tools so you will have good monitoring methods and robust data for finding and fixing any issues.

Trouble #2: People not knowing how to work the system. Workqueues and reports are the main ways for the non-compliant payments to appear. If those workqueues and reports are set up, you still need people to work them. Are they broken down properly by impact and volume, payor, aging date, dollar? All systems have the ability to move accounts out of their workqueues into someone else’s or to make some status that makes the account disappear. Are your thresholds for disappearance too loose or too strict? Are the workqueues being worked? Do they exist? There’s your trouble.

The fix: In order to have people know how to work the system, the system has to be set up to meet the needs of operations. Sometimes training is enough to get the workqueues functioning in the hands of the users. Sometimes you need a whole reset depending on if the system was set up as it is needed today.

Trouble #3: Reports not showing the real story.  Do you have some redundancy in reports to look at what should have been found in the workqueues?  Do you have a way to look back and see if there are some trends of write-offs or denials that somehow aren’t seen on a one-by-one basis? Reports should not mimic exactly the workqueues, however they should show both by summary and by detail the picture of each of the areas above — underpayments, denials, short pays, no pays and zero pays – and the potential causes of people, process, or system issues.  Are there trends by provider or department? Can you can portray these trends graphically? There’s your trouble.

The fix: We can go back to the old stand-by of paid, unpaid, and not billed reports, grouped by provider, by department, by payor. The story will emerge.

Hope is not lost. Sometimes you can get the help you need from your software vendor. Sometimes you need some outside help to get you on track. Of course you can call me to chat. Maybe your situation is better than you think 😊.

For as few as four hours a month or one-hour sessions, Jodi, Lori and the BRC team of Payor Contract Management specialists are available to offer as-needed mentoring sessions. BRC is ready to assist you via a phone call or web meeting to provide the guidance, coaching, and support you need to be successful. Together, we have almost a hundred years of experience! Certified in Epic HB and PB Contracts, HB and PB Clarity, and versed in five other systems, we can help you today!

Call 615-373-1466 or contact jodi@bloomroad.com to explore your options. 

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