Healthcare payer issues can be frustrating and time-consuming for both providers and patients. Whether it's a denied claim, a coding error, or a contract dispute, you need to know how to handle these situations effectively and efficiently. Here are some tips to help you resolve healthcare payer issues and improve your revenue cycle and patient satisfaction.
The first step to resolving any payer issue is to understand the payer's policies and procedures. You should review the payer's provider manual, contract terms, fee schedule, and claim submission guidelines. You should also familiarize yourself with the payer's appeal process, deadlines, and requirements. Knowing the payer's rules and expectations can help you avoid common errors and disputes, and prepare you for any potential challenges.
WIthin the NHS in England, this means working through the national coding standards, grouping, activity reporting, pricing rules, prices themselves and national standard contract (and associated technical contract guidance) which include local service specifications. Literally thousands of pages of guidance, published in several different places, at different times and some aspects only published behind password controlled areas.
The second step to resolving any payer issue is to communicate clearly and professionally with the payer and the patient. You should document every interaction and correspondence with the payer, including the date, time, name, and details of the conversation. You should also keep the patient informed of the status of their claim, the reason for any denial or delay, and the steps you are taking to resolve the issue. You should use polite and respectful language, avoid emotional or accusatory statements, and focus on the facts and evidence.
Whilst this is true, generically, within the NHS it is arguably more important to ensure you follow the contractual timetable for activity dataset submissions, financial reconciliations, raising and resolving queries and then the dispute resolution process should that be required. As the NHS is, mostly, free for the patient, then I would recommend protecting the patient from these kind of conversations/processes, especially at a time when they are most vulnerable.
The third step to resolving any payer issue is to follow up and escalate if needed. You should track the progress of your claim or appeal, and contact the payer regularly to check the status and request updates. You should also keep a record of the responses and outcomes you receive from the payer. If you do not receive a satisfactory resolution within a reasonable time frame, you should escalate the issue to a higher level of authority, such as a supervisor, manager, or director. You should also consider involving a third party, such as a professional association, a regulatory agency, or a legal counsel, if the issue is complex or contentious.
Where the NHS is the payer then it is important to follow the contractual dispute resolution process. So firstly discuss it locally, then escalate it up then a second stage of escalation (ideally to people not previously involved in the issue). If that does not work then it is mediation and then expert determination. Having sat on an arbitration panel for several years it is very very rare that I would recommend legal counsel but rather I would recommend ensuring you know how the detailed national contract and associated guidance applies to the issue at hand.
The fourth step to resolving any payer issue is to analyze and improve your processes. You should review your payer performance metrics, such as denial rates, payment rates, and turnaround times. You should also identify the root causes of your payer issues, such as coding errors, documentation gaps, or contract violations. You should then implement corrective and preventive actions, such as staff training, quality checks, or contract renegotiations. You should also monitor and measure the impact of your actions on your payer relations and revenue cycle.
Completely agree - taking learning points and addressing them where relevant is an important point to avoiding future disputes.
The fifth step to resolving any payer issue is to build and maintain positive relationships with your payers and patients. You should treat your payers as partners, not adversaries, and seek to understand their perspectives and goals. You should also appreciate and acknowledge their cooperation and assistance, and provide them with feedback and suggestions. You should also treat your patients as customers, not liabilities, and seek to meet their needs and expectations. You should also educate and empower them to understand their benefits and responsibilities, and to advocate for themselves.
Within the NHS in England both payer and provider utilise the same coded activity (contractually required Commissioning Data Sets regardless of whether NHS or Independent Sector provider) with national solutions already in place for this information to be shared between both parties (Secondary Uses Service) and for this very detailed information to be then reconciled to bills using the additional national information flow known as Aggregate Contract Monitoring data set. So typically, in the NHS, it is not data flows but rather queries on the detailed data that is not answered in that data that impacts relationships. For example - was the readmission avoidable, why was it a multi professional attendance etc.?
Both payer and providers share the same goal of providing highest quality care at lowest possible cost to their patients. Payer primarily use claims data and providers clinical data, and a long term data sharing strategy must be established between the two parties. Investing in technologies that reduce administrative burden on providers giving them timely and accurate access to quality clinical data and reducing common billing errors should tie in to the overall data sharing strategy. This will improve communication and strengthen payer-provider relationship leading to innovation in new risk-sharing and re-imbursement models.
The sixth step to resolving any payer issue is to learn and adapt to changing scenarios. You should stay updated on the latest trends and developments in the healthcare industry, such as new regulations, technologies, or models. You should also anticipate and prepare for any potential changes or challenges that may affect your payer relations and contracts, such as mergers, acquisitions, or audits. You should also seek and embrace opportunities to improve your skills and knowledge, such as webinars, workshops, or certifications.
Completely agree although remember to include staying up to date on how national guidance is changing - for example, within the NHS the Elective Recovery Fund guidance has a big impact on commissioners ability/willingness to commission and thus pay for more activity..