Q2 2022 Newsletter - PMRG

PMRG – Your Contract Management Partner

As your revenue cycle management partner, PMRG can help ensure that you, our client, are getting paid appropriately and according to your managed care agreements. Gone are the days when physicians could simply trust that they were getting paid fairly and accurately or in accordance with the executed healthcare contract. The reimbursement aspect of your contract is just one small piece of the contract puzzle. We can help track key contract elements that can affect timely payment from the carrier, the timely filing limit to submit claims, the time allotted to appeal a claim denial, as well as the “look back” period in which the carrier is able to recoup money on previously paid claims.

Healthcare contracts need to be reviewed carefully. Many physicians sign contracts without challenging or negotiating payor rates. Contracting with payors is not just a one-time event and then out of mind. Healthcare contract management involves performing an annual analysis. To do this, we can create, maintain, and review your practice’s fee schedules with the insurance carrier then annually run a reimbursement analysis to ensure your practice is being reimbursed at the contracted rate. We can help identify carriers who are grossly underpaying you when compared to other commercial contracts. We can assist your practice with contract negotiations or renegotiations.

Lastly, as insurance carriers change and / or update their policies, we can take the work of keeping up with these ever-changing rules for you. We can track the insurance carrier claim edits to determine which carriers may not reimburse for certain services/procedures when billed with other services rendered, as well as track changes in insurance carrier administrative, medical, payment and reimbursement policies that affect your practice’s bottom line.

While PMRG does not offer contracting services, we can help your practice with any part of—or all of—insurance contract management needs you may have. If you are interested in finding out more about how we can support you, or for pricing, please contact me at jholt@medicalpmrg.com.

Compliance Plans:

We have all heard of Compliance Plans. Many practices have a “cookie cutter” compliance plan—purchased, downloaded, or copied from another practice. There are also companies that offer standardized or generic compliance plans. Although it may seem the easiest way to be “compliant,, if your compliance plan is not personalized for your practice, you could face scrutiny from the OIG.

Organizing, implementing, and maintaining your compliance plan is one of those projects that we all plan to get to but never seem to have enough time for, since our efforts are focused on the day-to-day running of a medical practice. Or, if you are a physician, you’re focused on seeing and taking care of your patients.

The Affordable Care Act requires that the U.S. Department of Health and the OIG publish regulations that require most healthcare providers and durable medical equipment suppliers to establish compliance programs. In 2018, compliance plans were no longer optional, as they had been for many years. That year, CMS finalized the requirements for provider compliance plans; the implementation of a compliance plan is now required to participate in Medicare and Medicaid.

The OIG has identified seven elements of a compliance plan:

Standards, Policies and Procedures
Compliance Program Administration
Screening and Evaluation of Employees, Physicians, Vendors, and Other Agents
Communication, Education and Training on Compliance Issues
Monitoring, Auditing and Internal Reporting Systems
Discipline for Non-compliance
Investigations and Remedial Measures

Compliance plans do not come “one size fits all.” A compliance plan that makes sense for a large practice with multiple providers and employees may not make sense for a one-or two-provider practice with a few employees. Finding or crafting a “right-sized” compliance plan is key! Once you have found a compliance plan that works for your practice, don’t just put it on a shelf to gather dust. You must review, update and maintain your compliance plan on a regular basis to reflect that compliance is a priority to your practice, identify potential fraud and abuse risk areas within your practice and manage all financial relationships.

Let PMRG be your partner in compliance. If you need assistance reviewing or updating your compliance plan, don’t hesitate to contact me at jholt@medicalpmrg.com.

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