The Financial Risk Doctors Overlook...

As a physician, staying current with your payer contracts, credentialing requirements, and billing protocols is essential, but it’s an area that is often overlooked.

When was the last time you reviewed your payer submission guidelines and credentialing requirements? Physicians don’t have a lot of time for this part of the job. However, it is just as important as clinical care. You work hard for your patients, make sure you get paid for the work you do.

How Credentialing Impacts Your Practice

Being properly credentialed is critical to getting paid for the services you provide. If your credentialing is not current or a payer’s requirements are not followed, you could face zero reimbursement, claim denials, payment delays, account deactivation, or even loss of participation status.

Payer requirements can change from year to year, making it important to regularly review contracts, submission guidelines, and billing protocols. This is especially important when billing DME and orthotic items, where payer-specific requirements can be detailed and frequently updated.

Use Your Team!

Your billing and credentialing team plays an important role in maintaining your payer relationships. Make sure your team is:

1. Reviewing payer contracts and participation status regularly

2. Monitoring changes to payer billing and submission guidelines

3. Following up on credentialing applications and revalidations

4. Providing you with clear status updates and documentation

5. Identifying potential issues before they result in claim denials

6. Reviewing your contracts for carve-outs and special reimbursement provisions

Don't Forget About Carve-Outs

Carve-outs are specific services, procedures, or products that have been negotiated with a payer to be reimbursed at a specific dollar amount or percentage of the payer's fee schedule.

These negotiated rates are often easy to overlook when contracts are renewed or updated. And sometimes, the payer simply doesn't apply the contracted carve-out correctly when processing a claim.

Your team should know what carve-outs are included in your contracts and routinely compare your contracted rates to your actual payments. If a payer pays less than the negotiated amount, don't assume the payment is correct. Investigate it and follow up.

Your contract is only valuable if you know what it says, and make sure the payer is following it.

Most importantly, remember: ultimately, the provider is responsible for ensuring that their practice remains properly credentialed and compliant with payer requirements.

Your team can do the follow-up, but you should know the status of your credentialing and payer contracts.

Still Getting Denials?

Even if your credentialing is current, you may still be experiencing denials related to DME, orthotics, documentation, authorization, contract terms, carve-outs, or payer-specific billing requirements.

That’s where ToeTatics can help.

We can help identify the reasons behind recurring denials, review payer requirements and contract provisions, and help your practice develop a stronger process for staying compliant and getting paid.

You provide the care. Make sure you’re getting paid for it.