Continuum Service Spotlight: Payer Relations

Posted by Continuum on Mar 8, 2016 3:37:22 PM

signing_document.jpgMost physicians expect to receive the maximum reimbursement from payers for services rendered. Yet, many physicians are reimbursed at lower rates or are not fully reimbursed according to agreement terms.

Physicians often sign agreements without negotiating rates with the payer. “The payer will often tell the physician the average rate for their market, and the physician accepts the terms,’” according to Kelli Huber, Continuum’s Payer Relations Manager. Without a payer relations expert to help negotiate rates, physicians may lose out on significant reimbursement. Continuum’s team meets with payer representatives, presents clear data and requests adjustments or changes where needed.

Once a contract is finalized, Continuum’s Payer Relations team populates the agreement terms into Continuum’s Contract Manager application within the Continuum Platform, allowing for accurate monitoring of payments. Continuum's proven methodology is shown below:


If the payment is not equal to the amount outlined in the contract, the team goes back to the payer for reconciliation. Without a technology-enabled team of experts, the process would be inefficient and difficult to manage. How much could your practice be losing? Between January, 2011 and December, 2014, Continuum’s Payer Relations team identified more than $9 million in underpayments for its clients.

Continuum’s Payer Relations team also identifies payer trends that affect physician reimbursement and claim denials. For example, is a specific code denied on a regular basis? Or is the wrong amount paid on specific codes? If such patterns emerge, the team circles back to the payer to discuss their findings and rectify the situation.

Consider working with a practice management expert to ensure that your practice is properly reimbursed for your services.

In the meantime, here are several steps you can take to maximize your reimbursement:

  • Make sure all providers’ credentials are up to date.
  • Ensure all providers are credentialed with the contracted payers.
  • Obtain all referrals and pre-certifications prior to the patient’s visit.
  • Timely filing is critical to collecting payment. Keep in mind that delayed filings not only delays payment, but could also reduce the payment under certain contracts.
  • Follow-up promptly – Maximize reimbursements by reviewing all denials within 72 hours and act on them within seven days.
  • Analyze your denials. – Run your denial report and analyze the results. Why are claims being rejected in the first place and how can you rectify the situation?
  • Organize your denials – Separate those that are easy to explain and correct (i.e. a missing middle initial or date of birth), from those that require further investigation.
  • There is benefit in numbers. The larger the organization, the greater the leverage. Consider participating in a larger group, such as an Independent Physician Association (IPA).
  • Optimize technology – Is your staff properly trained to use any existing billing or EHR tools in your medical practice? If not, consider additional training to improve the practices' overall performance.

Download our whitepaper to learn about the challenges associated with next generation RCM and how providers should respond. 

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