Any group practice is likely to deal with several payers, each with a complicated contract that has a variety of stipulations and provisions.
Keeping track of it all – or, rather, trying to – would leave Shannon Tacker unable to answer a seemingly simple question.
A couple years ago, Tacker, director of reimbursement for UT Medical Group, would regularly be asked at executive meetings if the organization was getting paid appropriately.
“I would hem and haw around it,” she recalls.
Even though she was applying solid accounting principles and throwing staff hours at the question, it was hard to answer until UT Medical Group – a private practice arm of the University of Tennessee Health Science Center faculty – applied contract management technology to the problem.
Tacker first used a claims scrubber to try to improve the chances that claims would be approved on the first pass. Then, she tried having her staff follow up on payments, using paper copies of contracts and fee schedules, factoring in modifier reductions and interpreting contract language.
“We tried to monitor it manually, but physician billing has always been more complex than hospital billing, and it’s become more complex over the past few years,” she said. “Because we’re a multispeciality clinic, rates can vary by specialty. Rates within one contract can vary as well.”
Payers seem to thrive on and benefit from complexity, she adds.
“If a payer is writing the contract, we have to be careful of the wording,” she said. “The contract will have wording that reverts back to the payer’s payment policies – that’s hardly ever in favor of the provider.”
Last year, UT Medical Group implemented a contract management application called Phynance from Austin, Texas-based MPV. The application aggregates contract definitions and then models the terms outlined in payer contracts, helping to identify problem claims. It also helps billing staff find specific contract language when they’re appealing payer decisions.
In its first 11 months with the new application, the medical group estimates it captured $300,000 in underpayments.
Tacker’s staff now works more efficiently and often has more information about the contract than the payer does, she said.
“You have good information, and payers trust that,” she said. “The application also helps to show us payer patterns, and we can use that at the negotiating table.”
Payers also respect UT Medical Group because it has the facts to back up its concerns about payment issues.
“It’s one thing to call them and say, ‘I don’t think you’re paying us right for this code,’ and it’s another to have the facts and reference their contract,” Tacker said. “They’re more willing to listen when you’ve got the details. It makes the entire process more efficient.”