Q3 2024 Newsletter

The Pros and Cons of Changing Systems

by Curt Hill

Are you thinking about switching things up and changing your practice management (PM) system, your EMR or both? If you are, you’re not alone! It is important to understand the ramifications of doing so. It’s also important to appreciate that the “grass is not always greener on the other side,” although people selling the systems will almost always tell you that it is.

The first and most important question to answer is this: what is your intention in switching systems—whether it be your EMR, your PM system, or both? Changing systems is a very big deal, generally quite disruptive, and often very expensive. So, weigh your motivation very, very thoroughly—is what you’re after worth the expense and disruption?

The second thing to recognize is that changing systems will never change insufficient or inadequate work processes. The same people will be using the new system as were using the old system, and if the structures and processes to efficiently run the practice are not in place, changing systems won’t fix it! Often, digging in and tightening up the structures and processes will obviate the need for a shiny new system—and it will be much less expensive and reveal what the true issues are.

Third, do you really need to change both? The notion that you need both your EMR and PM systems from the same company is simply not true. The current state of technology allows for seamless integration between a myriad of systems. You may find that, as a provider, you gravitate to one EMR above all others, and the PM system from that company isn’t best for your workflow.

If you want to talk to us about this—we’ve worked with many of the ophthalmology geared programs on the market—we would be happy to. We’re familiar with most of the strong points and weak points!
With all that said, if after weighing the pros and cons thoroughly, you decide to make the change, check with us! It is unlikely that changing your billing service partner at the same time will also be in your best interest. We currently work with several of the major systems and will always be happy to support your and your staff in making the change.
 

The Importance of
Understanding Payer Contracts

by Jana Holt

Understanding your payer contracts can affect denial of payment as well as the amount and timeliness of reimbursement.

Insurance payers are constantly making changes to contract terms: changing to their fee schedules; how they interpret contractual language; full-scale policy changes, etc. As a result, physicians and medical practice administrators must remain vigilant to ensure that they are being reimbursed correctly and competitively by their managed care payers. 

Provisions to consider when reviewing potential new or existing payer contracts are:

• Parties, plans and products

• Covered services

• Key definitions

• Credentialing requirements

• Payment provisions

  • Late payments/non-payments

  • Method of payment (VCC, EFT, Check, etc)

  • Prior authorizations

  • Submission of claims

  • Member responsibility and COB

  • Overpayments, repayments, future offsets

  • Appeals and dispute resolution

  • Reimbursement rates

  • Down-coding and bundling

• Policies, procedures and guidelines

• Utilization review and audits

• Term and termination

• Amendments (unilateral or mutual agreement?)

The last item to consider is the most alarming. Insurance payers can implement policies and amendments to contracts without mutual consent that can have a significant impact on reimbursement. This is called a unilateral amendment. A unilateral amendment means that payers can change contract provisions without notifying the physician. Some states require notification to the provider of any contract changes or amendment. If no state requirement exists, payers are allowed to amend the contract at any time and some without the approval of the physician.

Insurance payers can also implement new policies or policy changes at will. These policies can affect a variety of things including reimbursement for services, covered services, and medical necessity requirements. Most insurance plans communicate policy changes via a newsletter subscription that can be accessed on their websites or via email list serve. Be sure to sign up for any available notifications for payers you contract with.

Before signing initial contracts or renewing existing contracts, here are some things to consider:

• Review the contract entirely before you sign it

• Consider having a knowledgeable healthcare attorney review the contract

• Keep a copy of the signed contract and keep it accessible

• Know the process for reporting unfair practices by the insurance company within your state

While PMRG does not handle contract negotiations, we understand the importance of contract language and provisions included in provider contracts that can significantly impact your reimbursement. We encourage providers to understand their contracts and seek out assistance in negotiating a contract that is favorable to the practice and the provider.

Employee Spotlight:
Selena Wilcopolski

This quarter we’re proud to spotlight PMRG call center team lead Selena Wilcopolski.

Selena is the mother of three adult children, a mother-in-law, and the baby sister of eight siblings. She married her high school sweetheart and been married for 24 years. In addition, she is the proud "glamma" to two amazing granddaughters, whom Selena says keep her on her toes. 

Selena’s favorite hobbies are spending time with family, gardening, and decorating. She also loves to do home makeovers. 

Selena has been in customer service and management for most of her career, with about 10 years' experience in call center roles. 

“I started out as a representative at PMRG and learned a great deal from my amazing manager, LaMila,” says Selena. “This experience led me to become a team lead for our call center. I love being part of a team that has heart and enjoys working together toward a common goal.”