Medical Billing and Coding Teamwork: Working with Payers

By Karen Smiley

The revenue cycle of medical billing and coding requires teamwork in order to work efficiently. You may find yourself as the go-between for patients and their insurance companies. The patient (or his employer) is paying the insurance company, and, ideally, the insurance company pays the provider for services rendered to their common client: the patient.

In a perfect world, all patients would be fully informed about their plan benefits, but the reality is that they often aren’t.

Working with commercial payers and Medicare

Medical billers and coders work together with the payer to provide the best possible service to the patients. Many of the major players in the commercial insurance industry are household names: United Health Care, Aetna (which acquired Coventry), Cigna, and the big kahuna, the Blues: BlueCross/BlueShield (BCBS). BCBS has 38 different companies that operate independently yet allow full reciprocity among plans.

Reciprocity means that the provider contract with the local BCBS is in-network with all other BCBS plans except for insurance exchange plans (through the Affordable Care Act), which usually require separate enrollment and may not cover services outside the state of issue.

Commercial payers and Medicare usually comprise the majority of your payer mix. In some specialties, Workers’ Compensation may be well represented in the practice ledger. Some practices make a point to have contracts with the majority of commercial payers in addition to Medicare, and these contracts make the relationship a little easier to navigate; in most instances, the claim goes out per payer guidelines, and the payment comes in correctly per provider contract. Medicare transactions are similar; as long as the claims are submitted correctly, Medicare will pay per fee schedule.

You may find yourself explaining the difference between traditional Medicare and commercial Medicare replacement plans. Patients get confused and may not realize that Medicare Part A is hospital coverage only — that they need Part B for other services. They may not understand the difference between a Medicare supplement (only available with traditional Medicare) and a separate commercial plan that only duplicates Medicare coverage.

It can be heartbreaking when your patient realizes that the commercial plan for which he has faithfully paid premiums for years doesn’t cover the patient portion of Medicare-approved expenses and now he has a pile of bills to pay.

Getting involved with Workers’ Compensation

In contrast, Workers’ Compensation claims can be a challenge if you’re dealing with a state that doesn’t have a Workers’ Compensation fee schedule. The state may pay “usual and customary,” but what does that mean exactly? It means another step for the medical biller or coder.

At the very least, it should lead you to an appeal requesting just that: a definition for what the payer considers “usual and customary” and its supporting documentation for that guideline. Because “usual and customary” is a very subjective term, you should always challenge it.

You may find that the payer accessed a silent PPO (preferred provider organization) contract. When the payer or network indicates that it has PPO members, you should insist on a list of the payers who may access the network and also stipulate that your office be notified each time a payer leaves or enrolls with the network. That way, when Workers’ Compensation payer ABC claims to have accessed Network 123 for pricing, you can check your list and indicate that it isn’t included in your contract and must pay up!

By the way, most states have prompt pay laws that prevent payers from stalling correct claims payments. Find out what regulations your state has, keep a copy of them, and when a payer violates the law, send it a copy along with your request for the interest due.

Joining the claims process

When a claim doesn’t pay correctly, you need to follow up. Document all conversations — who, when, and what — and get a reference number. If the revenue cycle is being disrupted due to front-end issues, such as incorrect or missing payer information or inaccurate demographics in the software, address it with the front desk personnel and emphasize the importance of collecting the right information.

Offices that use electronic systems with patient self-registrations have fewer errors when required fields are programmed correctly.

Being part of an office team

You’re an advocate for your employer, and in this role diplomacy is very important. You should be firm but polite when dealing with both payers and patients as well as colleagues. Always align your position with correct coding practices in addition to state and federal laws; should you find yourself in a situation that you know encourages unprofessional or even illegal billing methods, look for another job.

Be aware of your employer’s policy when dealing with patients or payers, and always identify yourself up front. Some providers allow for a hard line with payers but prefer to have patients coddled. If you work in a billing company, it likely has very strict policies regarding phone etiquette because its fiduciary responsibility is to the client. The golden rule still applies: Treat others as you want to be treated.

If you’re working for a small physician practice, you can usually talk to the physician (bring your documentation) and explain why things may need to be changed a little. Try indicating that you think that the transcription service may have missed part of the dictation, or something along those lines. Discuss the need to validate documentation as protection from a payer audit, and make sure the physician knows that you want to protect the practice from financial setbacks caused by payment recovery actions.

The job of the medical biller or coder is to get the provider paid for services rendered. Whether the payment is coming from insurance or patients, you or the office must have a process for collecting. This process should be consistent and, above all, fair.