Payer Intelligence, Part 5
When to Review the Rules You Need to Know in Payer Publications

By Rayellen Kishbach, Director of Business Development for Policy Reporter

In Parts 1-4 of the Payer Intelligence series, we looked at a broad range of publications that Medicare and commercial payers publish to communicate coverage or non-coverage of a procedure, product, service or test. This final article maps where in the revenue cycle it is important to review specific types of payer rules.

Generally speaking, most coding and billing professionals don’t have time to do a full payer review for every claim. With good scheduling, medical necessity and payment edits in place, the system you use for orders, coding and claims will automatically apply payer logic for you much of the time. Here are a few places in the revenue cycle where it is important to review payer logic:

  • Denials and Appeals: When working denials or appeals, it is important to step outside of the claims system to see exactly what the payer thinking is on a specific service. For appeals that have aged a bit, this may require access to a past policy, rather than the current one published on the payer’s website. The team working the denials should provide a feedback loop to registration and scheduling to change how patients are scheduled and to clinicians or the ordering system to ensure documentation standards are updated.
  • Registration and Scheduling: For the most complex services, for services that are frequently denied, and for services that are known to require prior authorization, the time it takes to review policy and prior authorization requirements may save a lot of time down the line. Focus on your top payers and top volume and be proactive. One way to lessen the burden on your team is to encourage team members to become experts in specific service areas. Another is to let them each become the go-to for issues with a specific set of payers.
  • Managed Care Contracting: Payers update their policies continuously. Be sure to request a list of important service line changes that have occurred during the past contract year so that your upcoming year will reflect new realities. The list should include new technologies that are covered or excluded, increased prior authorization requirements, and new payment rules which impact the cost to do business with each payer. Throughout the year, review updates to policies in real time to scan for important changes.
  • Compliance: Obviously, compliance must proactively stay on top of government regulations, which are operationalized by CMS in the provider manuals. It is also a best practice for compliance to review top payer policy updates to check for places where significant operational requirements are communicated. These operational requirements include site of service, and which providers are qualified to perform a specific service, etc. Since 2020, the rules for telehealth, remote patient monitoring, and other digital health services have been rapidly evolving (with state-specific rules) so that is definitely an area to be on the watch for.

This “Payer Intelligence” series provides a set of quick tutorials on payer publications that support accurate coding and efficient revenue cycle operations.

About the Author
Rayellen Kishbach is a Director of Business Development for Policy Reporter, a TrialCard Company with over two decades of experience building and selling healthcare knowledge products. Policy Reporter provides an innovative healthcare software solution that tracks payer policies in real time wth customized alerts to subscribers. The company’s patented software-driven solutions include a suite of billing and reimbursement tools for providers and laboratories, market intelligence tools for payers, and a suite of patient access solutions for life science companies.

WE ARE HIRING. Policy Reporter is regularly recruiting and hiring for positions that can be a great fit for professional coders, auditors, and revenue cycle experts. From data quality to health document analyst to reporting and 1099 research contract positions, you might be a good fit if you have certification such as CPMA, CHDA, or CDIP and are good at synthesizing complex information and communicating clearly. Diagnostics and Laboratory prior authorization, billing and claims experience is a plus! Contact [email protected] for next steps in working with Policy Reporter.

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