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Medicare is going to be mailing all Medicare patients a new Medicare number and your practice needs to update their records.
In June, we posted an article about Medicare’s decision to stop using Social Security numbers. Your patients likely call this their Medicare number. Since the transition date is looming ahead we thought an overview might be helpful.
- The effective date is April 2018.
- The new Medicare number will be called the Medicare Beneficiary Identifier (MBI).
- Your patients will get new cards with the MBI on the card.
- You will no longer be able to identify Railroad Retirement Board (RRB) members by their Medicare numbers. You will be able to identify them by the RRB logo on their card.
- The MBI will have 11 characters. It is unique to each person and will be clearly different from the HICN.
- The MBI is randomly generated so there is no link or hidden information related to the patient.
- MBIs will fit on forms the same way HICNs do. You don’t need spaces for dashes.
- Here is an example of the way the MBI will look: 1EG4-TE5-MK73.
- Your office must be ready to accept the MBI by April 2018 for transactions such as billing, claim status, eligibility status and interactions with MAC.
- There will be a transition period when you can use either the HICN or the MBI to exchange data and information with Medicare. The transition period will start April 1, 208 and run through December 31, 2019. However, your systems must be ready to accept the new MBI by April 1, 2018.
- It is especially important that you are ready for people who are new to Medicare because they will only have the new MBI.
- Verify your Medicare patients’ addresses because they won’t get a new card if their address isn’t correct.
- Starting in June 2018, you can look up your patients’ MBI through your Medicare Administrative Contractor’s (MAC) portal when the patients can’t or doesn’t give them to you.
- You can get more information by visiting Medicare’s Card Home and Provider webpages at www.cms.gov/Medicare/New-Medicare-Card.
Medicare has stated that they will “work closely with other payers, State Medicaid Agencies, and supplemental insurers to make sure the crossover claims process will still work”. Please note that they are not guaranteeing it will work.
As with all things related to payers, Ben Franklin had the right saying, “Distrust and caution are the parents of security”.
Is it Time to Renegotiate Your Payor Contracts?
There are too many times to count where we’ve encountered physicians who haven’t renegotiated their payor contracts for years and sometimes never. If you fall into this category then don’t waste another minute. Don’t miss out on getting paid more for the work you are doing. Get those contracts out, dust them off and prepare to renegotiate.
The following steps will help you through the renegotiation process and alert you to some key terms that payors don’t want to include in your contract but you should make sure they do.
- Study your current contracts and fee schedules
- Review contract terms
- Know your term and termination language and notification requirements
Do Your Homework
- Generate a list of DX codes with frequency for the quarter and the year
- This will show you what codes you use;
- 20% of the codes are used in 80% of the cases and those are the ones you want to have the higher fees
- Know your highest volume CPT
- Benchmark reimbursements against the Medicare fee schedule
- Prepare and excel spreadsheet listing the top reimbursement and the top highest carrier.
- Know your practice model
- What makes your practice unique?
- Do you have an in-house lab, are you bilingual, do you provide consultations, are you double or triple boarded? Are there demographic advantages? Do you provide ancillary services? These things could get you higher reimbursements.
- Make sure you are on ACH for all carriers. Your billing service should do this for you.
Know what you Expect/Require from the Payor
- Do not allow the carrier to just look at your taxonomy number because they might not understand or see the whole picture.
- Require the carrier to review your prior utilization
- Address the top 25 used ICD-10 codes that you identified when you did your homework
- Determine carve-in and carve-out ICD-10 codes.
- If you have an evergreen contract (one that renews automatically) then you should have a set percent increase every year. If it isn’t an evergreen contract you have the right to renegotiate every year.
- Claim adjudication should be daily not weekly and make sure this is spelled out.
- When they ask for records, make sure the contract spells out the turn-around-time for their review. It should be 14 days.
- The contract should spell out the denials management process, i.e. TAT, appeals.
- How are refunds handled? Take backs should be written out of the contract.
- Check and comply with their CAQH and professional liability update requirements. You must stay updated or the can kick you out for non-compliance.
- Understand the language of the contract.
- Prepare an impactful proposal letter. This is a sales pitch. Most physicians don’t like to think of it as a sales pitch but that is what it is. Sell yourself and your practice.
- Don’t mention pricing at this point
- Send your proposal to a specific person, i.e. your network representative.
- Track it. The payor will take approximately 4 weeks to internally evaluate your proposal and do their utilization review.
- Follow up. Call every 15 days. Don’t be surprised if you get the run-around. Just hang in there, call and remind them that you have called before and that you are checking on the status.
- Do not accept the first round of negotiations. Always counter
- Evaluate, compare and decide on next steps.
- There will likely be things you like and don’t like but decide what is most important to you and be prepared to compromise. Both sides should win and lose something.
- Is the rate increase retroactive? If so, to what date?
- Before you sign, verify that the contract includes the reimbursement rates, the increases, and all terms.
- Sign the contract and return it certified mail.
- Tell your billing company. Your hard work will only pay off if you have good revenue cycle management. The billing company needs to know
- the new fee schedule;
- claim adjudication terms;
- denial management terms;
- turn-around times; and
- refund management terms
- Track your reimbursements
- Check EOBs for the first few months and periodically thereafter to make sure reimbursements are consistent with the new rates. If you have been underpaid you can rebill for the difference.
Renegotiating payor contracts is time-consuming and can be frustrating but it is so necessary. You already know that insurance companies aren’t going to look out for you. You must look out for you so start today and take it one step at a time until you get your raise.