Hospitals Face a Complex Billing Situation in Today’s Insurance Environment

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Healthcare costs are higher than ever, and providers often find themselves dealing with reimbursements that are less than expected. Hospitals should review their contracts carefully in these cases.

What Is the Standard?

The Centers for Medicare & Medicaid Services (CMS) provide a framework for medical reimbursements that many healthcare providers assume will be the norm going forward. However, insurance companies continue to strategically limit their risks by negotiating contracts that may differ from these standards. Executive level managed care expertise is required to negotiate contracts in cases like these.

Ensure Payment Within Terms

Healthcare contracts are one thing; getting paid within terms is often another challenge. Your collections department must be on top of trends with your patients and their insurance companies to ensure that you collect as much as possible.

Code Correctly

Insurance coding is complex at best. Numerous articles in the popular press have introduced the public to the ridiculously specific nature of these codes. For example, “W61.62XD Struck by duck, subsequent encounter” and “W22.02XD Walked into lamppost, subsequent encounter” are two codes that illustrate this. With this many insurance codes, your staff may need professional training to understand what codes can legitimately be used which will get the maximum reimbursement that your firm is entitled to.

Negotiate to Keep Your Hospital Profitable

If you’re running a for-profit medical institution, you may find you need executive level managed care expertise to negotiate non-standard terms. Insurance contracts are a two-way street; the insurance companies must keep medical facilities available for their members to retain market share, and for you to continue to serve you need to be profitable. Even if you’re operating as a non-profit, your revenues must exceed ordinary expenses to allow for continued investment in your infrastructure.

For your institution to survive and thrive in today’s compensation environment, you’ll need to manage all of these areas carefully. You owe it to your patients, staff, and medical providers to continue to be the best facility you can be.


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