纳税人 are continually looking for ways to implement cost savings for employer groups, and this has resulted in the inclusion of language in facility contracts with providers that can restrict, 减少, and deny payment. 纳税人 are getting creative and including new types of restrictions and requirements in Ambulatory Surgery Center (ASC) contracts and amendments; for example, 他们可能会在他们的在线提供商手册或提供商更新信中进行更改,而这些更改永远不会提交给您审阅.
在签署ASC合同或修改之前阅读并在收到最终版本后再次阅读比以往任何时候都重要. 我们建议强调影响您的业务办公室报销的关键合同付款条款和语言条款,以便它可以操作合同义务,并将其纳入政策和程序,以最大限度地提高合同费率,避免收入损失.
兼顾合同的时间框架和规则可能很困难,因为它们可能因计划而异,甚至可能因同一健康计划中的不同产品而异. 您应该建立一个合同方法跟踪机制,以便您的员工能够使您的ASC业务办公室符合规则,并适当地更新每个付款人和每个合同中的各种产品的索赔系统. This can also help you and your staff identify trends and issues with various payers.
Below are 10 important managed care contract considerations that you should review with your ASC business office. 制定明确的政策并为每个人分配责任,以便您的业务办公室实现ASC合同的价值,并从所有付款人那里收取100%的到期报销.
1. Timely Filing Requirements
As electronic filing becomes the norm, 付款人继续缩短提交索赔的时间(我们在ASC合同中看到这个时间框架短至5天),并设定了包括不支付全部索赔在内的经济处罚. Be sure your business office knows the timely filing rules for each payer and all products in that contract. 在很多情况下, 医疗保险优势的及时提交限制将比商业产品的时间更长,因为医疗保险规定了及时提交限制. Don’t assume that one payer has the same timely filing requirement for each product in the contract.
2. Dispute-Resolution Time Frames
Be sure to document in your policies and procedures the timeline to dispute a claim and file an appeal. The timeline normally starts from the receipt of payment from the payer. Many payers are reducing this time frame to one year or less from the date of service or payment date in ASC contracts.
3. Take-Back Process and Time Frames
Outline the time frame in which your business office must process refund checks to payers in the case of overpayments. This varies from payer to payer. Many plans only allow a month or less from the time your business office is notified to return the overpayment. If this overpayment isn’t returned, the payer can offset future payments, which can be time consuming to process for the business office staff. 拥有一个向付款人发送退款的流程将节省您的业务办公室在未来发布部分付款的时间.
4. Contractual Obligation to Follow Provider Manuals, Including Electronic Update Requirements
确保有一名ASC业务办公室代表负责定期检查提供商手册的各种更新, as well as newsletters and written updates from payers. 这是业务办公室中的一个重要角色,帮助确保跟踪付款流程的任何更改,这些更改可能会对报销产生重大变化,然后将其包含在业务办公室的政策和程序中. 付款人正在从寄信和纸质通知收费表和政策的变化,转向通过电子通讯和网站手册进行更新. Most payer contracts reference provider responsibility and obligation regarding published changes in the provider manual. You must read the fine print under “provider responsibilities.” This means that the ASC is responsible, 业务办公室代表应负责定期搜索付款人提供的在线工具,并遵守任何公布的更改,因为ASC必须按照合同语言遵守.
5. Time Frame for 访问 to Records
Many payers are requiring a quick turnaround time frame when they request clinical or billing records from ASCs. The time period for providing information requested from a payer is often included as part of the payer’s contract terms. 确保ASC业务办公室团队了解这些条款以及在需要时向计划发送信息所需的时间表.
6. Contractually Required Information Disclosures to the Payer
Check the contract for any information or updates that you are contractually obligated to send to the payer; this can include changes to the provider roster, 的认证, 所有权, or management of the ASC. 请注意,如果不遵守向付款人提供这些信息的合同义务,将会受到任何罚款.
7. Financial Penalties for Missing Time Frames
It is important to review contract terms to determine how long the ASC has to file a claim with each payer. Not all payers have the same timely filing requirement, and penalties may vary when applicable. Most payers are moving toward nonpayment of claims that are received after the timely filing period, and many payers are reducing that time frame in new contracts so it may change when you renew your contract.
8. Financial Penalties for Facility-Based Physicians Who Are Out of Network with a Payer
许多大的付款人在合同中加入了允许付款人在特定时期或无限期地减少总付款的条款,如果ASC利用非参与机构的bet8网站备用提供bet8娱乐. This includes but is not limited to anesthesiologists, 放射科bet8网站备用, and pathologists, otherwise known as “hidden providers.”
9. Payer Methodology Variations
Review payment methodologies’ logic and terms in their entirety. 在进行合同审查时要回答的其他一些重要问题是:付款人如何报销在您的ASC有多个程序的病例? Do they pay additionally for implants? Does the contract include surgery codes that are carved out of the methodology and paid at different rates? Are there any variances in how the payer reimburses for different products? 例如, 商业案例的报销方法是否与医疗保险和医疗补助优势计划案例的报销方法不同? Is there an annual escalator to rates, and how do you account for these updates in your claims payment tracking system? How do you communicate contract rates to the business office? These are questions you must work through and review with your business office staff to ensure standards are established.
10. Payer Contract Renegotiation Renewal Date Responsibility
If the term of the contract is for three years, track the term and approach the payer to renegotiate the contract. It’s important to request an increase, 因此,计划在您可以行使终止和/或合同的最后期限之前大约8个月或更长时间联系付款人,以便您有时间在下一个合同期限开始之前重新谈判费率. 纳税人 will not reach out to you to increase your rates, 他们通常会在合同中有语言允许最后一组费率继续-这取决于你谈判你的ASC合同!
The Importance of Contract Management and Diligence
In addition to providing exceptional clinical services at your ASC, 管理好付费用户关系的一部分是确保你的团队了解并有能力遵守这些规则, 规定, and time frames specified by the different payers. 基于付款人期望和要求的政策和程序的实施是合同管理的重要组成部分. 这是一个好主意,每年检讨你的合同,以确保你的办公室符合所有付款人合同的要求. 关注这10个关键因素将有助于您的ASC减少损失并优化收入,同时保持与合同付款人的良好信誉.
Published September 19, 2018