{"id":676,"date":"2012-12-11T12:26:15","date_gmt":"2012-12-11T12:26:15","guid":{"rendered":"https:\/\/www.billingparadise.com\/blog\/?p=676"},"modified":"2022-06-06T06:53:55","modified_gmt":"2022-06-06T11:53:55","slug":"understanding-payer-contracts","status":"publish","type":"post","link":"https:\/\/www.billingparadise.com\/blog\/understanding-payer-contracts\/","title":{"rendered":"How the Payer Contract Should Be?"},"content":{"rendered":"

Collection Formulla<\/span><\/h2>\n

The collection rate of a healthy clinic, often defined by the following formula, is expected to be above 95%, but more often than not many a practice bleed a lot of money due to improper preparation and understanding of the payer contract.<\/p>\n

Collection Rate = \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Total Collections\/(Total Charges \u2013 Adjustments)<\/p>\n

To be able to bill accurately, the in-house or outsourced medical biller should be in touch with the latest version of payer contract obligations, which includes but are not limited to the following:<\/p>\n

a. The Fee Schedule of the Products.<\/p>\n

b.\u00a0 The rules of payment.<\/p>\n

c.\u00a0 Preauthorization criteria.<\/p>\n

d.\u00a0 Submission time frames.<\/p>\n

Nature of Contract<\/span><\/h2>\n

Insurance companies most often than not offer standardized contracted rates to providers, but the buck does not stop there.\u00a0 The content & language of the contract should be able to protect the provider from any amendments that the payer may come up with a very short notice period.\u00a0\u00a0 Besides, a clinic has to be precisely aware of the nature of the so called \u201cdeal breakers\u201d such as<\/p>\n

1.\u00a0 The number of procedures permissible for a service date.<\/p>\n

2. The nature of the multiple procedure reduction <\/em>or MPD.<\/p>\n

3.\u00a0 Implant allowances.<\/p>\n

4.\u00a0 Special payer EDI rules of submission. etc<\/p>\n

Billing Skyfalls<\/span><\/h2>\n

In the eventuality that the payer does not seem to honor a well-prepared contract for a claims submission<\/span><\/strong>, the appeals process should be quite easy.\u00a0 You just go ahead and intimate the payer via a letter that you haven\u2019t been paid as per the contract.\u00a0 A well-structured payer contract can go a long way in shielding you from any unexpected medical billing <\/em>skyfalls.<\/p>\n

Remember that the medical billing process<\/strong><\/span> begins even before that first claim first has been submitted; in fact even before the first patient is seen for the year; it begins when the payer contract agreement is taking shape in the forges of the medical billing cauldron.<\/p>\n","protected":false},"excerpt":{"rendered":"

Collection Formulla The collection rate of a healthy clinic, often defined by the following formula, is expected to be above 95%, but more often than not many a practice bleed a lot of money due to improper preparation and understanding of the payer contract. Collection Rate = \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Total Collections\/(Total Charges \u2013 Adjustments) To be […]<\/p>\n","protected":false},"author":2,"featured_media":680,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[745],"tags":[],"class_list":["post-676","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-coding"],"_links":{"self":[{"href":"https:\/\/www.billingparadise.com\/blog\/wp-json\/wp\/v2\/posts\/676","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.billingparadise.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.billingparadise.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.billingparadise.com\/blog\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.billingparadise.com\/blog\/wp-json\/wp\/v2\/comments?post=676"}],"version-history":[{"count":0,"href":"https:\/\/www.billingparadise.com\/blog\/wp-json\/wp\/v2\/posts\/676\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.billingparadise.com\/blog\/wp-json\/wp\/v2\/media\/680"}],"wp:attachment":[{"href":"https:\/\/www.billingparadise.com\/blog\/wp-json\/wp\/v2\/media?parent=676"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.billingparadise.com\/blog\/wp-json\/wp\/v2\/categories?post=676"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.billingparadise.com\/blog\/wp-json\/wp\/v2\/tags?post=676"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}