Payor challenges: Best practices and why outsourcing can help
When it comes to reimbursement in the world of post-acute care, especially home health and hospice, it’s common for some payors to present more challenges than others. These payors may have more submission requirements, such as medical records or other specific documentation, which can lead to prolonged reimbursement.
In this blog, we dive into how to identify these payor challenges, tips for addressing them, and why outsourcing revenue cycle management (RCM) services might be the answer for your agency.
5 signs that a payor may cause revenue challenges:
- The payor makes contracting difficult. If a payor turns down a contract, which may happen if they have enough providers in network, it can cause challenges for your agency to fight denials, to create a fee schedule, to know reimbursement rates, or to even set the payor up.
- The payor has a prolonged turnaround time. Whether it’s due to additional requests such as medical records or having to appeal to get movement, a payor that typically does not provide payment in the first round will likely be an ongoing challenge.
- The payor consistently underpays. If the payor has a low payment rate that must be appealed consistently, reimbursements will always be delayed.
- The payor uses down coding to recoup claims. It’s not uncommon for payors to reimburse correctly, but then down-code HIPs incorrectly to then pay at a lower rate and take money back from providers.
- The payor has different requirements for different plans. When payors have tiered plans, they often have different documentation requirements. This can lead to incorrect submissions, which can then lead to denials and revenue delays.
Payor challenges are also caused by government regulation
We can’t discuss payor challenges within home health and hospice without also considering Medicare and Medicaid.
For Medicare Advantage, one of the most common issues is if you are out of network and have no contract, payment will typically not be processed. If the claim is not processed the first time, a waiver of liability (WOL) must be signed for each claim or appeal. The WOL states that regardless of the outcome of the claim, you will not bill the patient because you are not a contracted provider.
Medicaid also puts forth ongoing payment challenges, one of which is the Electronic Visit Verification (EVV). With the launch of EVV in all states, it’s common for the aggregators to not correspond correctly with the payors. Another challenge comes from the rules surrounding room and board with state-specific payors. Many facilities fail to meet these requirements, which complicates billing for the agency.
Best practices for troubleshooting payor challenges
In home health and hospice, the payor issues can seem never-ending. And as revenue cycle management experts, we have a few tricks to alleviate these challenges.
Root cause payor issues.
By putting all of a payor’s issues under the same root cause, you will have an efficient strategy to figure out a bulk payor problem. For example, if you’re experiencing a trending denial due to a missed request for additional medical records, root causing that additional request will alert your team to confirm whether their contract is valid or current.
Prioritize trending and analysis.
If payor issues are correctly root caused, trends should be easily visible. Having this information organized and readily available allows agencies to analyze what happened and how to fix it.
Realize that many payor issues start at intake.
Insurance verification at intake is where many root causes begin and are not caught until the first claim goes out. This is a significant challenge because many payors will not retro-authorize payment if the patient has been discharged. It’s important to verify insurance and determine eligibility at intake by establishing workflows to ask all the right questions and document accurately.
We understand the challenges that come with navigating payor relationships in home health and hospice — but you don’t have to face them alone.
Connect with us today to learn the benefits of RCM outsourcing and how our billing experts can help improve your revenue strategies.
Danielle Stucke
Danielle Stucke, Supervisor of Billing Services at MatrixCare, is an accomplished professional with a strong background and extensive working knowledge of the revenue cycle in home health and hospice. As the supervisor of billing services at MatrixCare, Danielle oversees the billing services team, utilizing her comprehensive understanding of all phases of the revenue cycle to drive operational efficiency and financial performance. Her commitment to excellence and dedication to resolving payor billing issues have solidified her reputation as a trusted leader in the field.
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