Bonus: 5 Contract Clauses Killing Your Reimbursement

This bonus episode is a recording of my recent webinar with hbma, which was actually qualified for and folks did receive continuing education credits and I always wanted to be a professor, folks. Getting credits from my lessons gives me particular pleasure.So I figured since I'm having such pleasure, I would extend that over to you and bring some joy as well as insights into your life and make this recording accessible via a bonus episode. As you could see, the it's very long.The length of this episode is many times what our typical length is, but I wanted to put it out there for you so that you can have it as a resource. Here it is.I'm going to make sure you walk away with some practical takeaways here. It looks like we do have a very nice showing today. Let me first do an introduction. I'm Alex Yarijanian.I have a long healthcare administrative background from managing clinics across various states providing primary care, mental health, substance abuse treatment services. I then worked at Cardinal and HCA Hospital System, so I really got a good lay of the land for what that looks like right in the hospital system.I then worked at Humana Health Plan as the head negotiator and network management person for the West Territories. So then I got to see the health plan side I think.So I left late 2018 to start this company called Carenodes, which essentially has really been focused on closing the asymmetry in knowledge between payers and providers.What I want to talk to you about today, when I deal with many providers from telehealth to inpatient, outpatient, you name it, and a lot of times we'll come to RCM issues. Billing problems are not always RCM problems, right? They could be contract problems that are invisible.What I want to talk about is how do we identify the contract problems from the billing problems and how do you rectify that with your management team or with your contracting team? We're going to talk about the seven provisions you guys I see time and time again that really make me cringe but really cause billing failures.I'm going to share a contract audit framework and I also have a PDF you can take away with you that has the checklist and the audit. The question here is how much of your denied revenue is really a contract problem? You guys, I deal with this day in and day out.United portal, the Availity portal, the health exchange, you name it, right? There's very little time to now go investigate the contracts to see how much of it is contract problems.So the distribution that I heard tracks okay, so where are the errors born? You might be surprised to know that 73% of providers don't know what they're actually supposed to get paid. This kind of tracks.So here's the order of issue. You have contract language that feeds into fee schedules and exhibits, impacts those fee schedules and exhibits.And all you have is just like the fee schedule. Right. But the contract language adjudicates the fee schedule system build and payer rules come in.And that's beyond your scope of this is even beyond the contract. Right. Because contract will read subject to the policies that are online or wherever. Right.So then it actually changes your contract without you really knowing. Right. Unless you're keeping on top of every single payer update possible. So I'm going to say this is where the errors are born, contract language.And they're inherited by the time it gets to you and you have to do your workflows. What was the fee schedule mismatch and what was the effective date for those changes? Are you indexed to another year's Medicare rate?So non covered denial? What are your carve outs? Payer responsibility confusion? What is the coordination of benefit language in the contract?Timely filing denial happens all the time. But how is it possible that the payer's contract language supersedes law? It cannot be right.Because certain types of patients, medi medi patients versus commercial patients have different timelines of denial management and adjudication. So you always want to cite the state as well as federal guidelines for that. And I have templates with these language. I'm happy to share.I thought it might be helpful to give you example of language that I've seen in contracts that caused this type of issues. So issue one Fee schedule and effective dates and updates. Okay, so I had an issue where I was maybe I should name the payer.It was a big payer and essentially the effective. The effective date of that agreement wrote effective upon execution by both parties. Okay, simple enough.But what happened was actually there was a 60 days or so delay between the time where we signed the contract and when the payer signed the contract. And in between that time the rates had changed because it was a proprietary fee schedule indexed to some scheduling ability. Okay.That had changed from the time where we signed the contract to time where the payer counter signed it. That is a major problem. Right?Because when the effective date isn't clear, then what you're running into is potentially changes into those schedules that you initially agreed to.So now you have to go back to contracting and have them make sure to see Whether the language in the agreement allows the plan to amend your contract from time to time without notice or with a small number of days noticing or without mutual agreement. So these are red flags.And you should certainly look into these contracts right when they're put into effect and see whether the amendment provisions or the modification provisions impact your fee schedule. Because that's a major issue. Right.So no process for annual rate updates.So when you look at the contract, it should tell you we update your rates quarterly, annually, every time CMS updates it or some random cadence from time to time. That's an issue.If you have the power to negotiate that time to time language at out of there, negotiate it out whenever you see time to time may change this rate. Time to time may do systematic updates. A payer might do systematic updates. So this, this kind of language is a major problem.Contracts that have multiple product lines are not aligned, aligned to a single fee schedule. They can each change a different cadence.So then it becomes like having to run after the fact as opposed to teeing it up at the get go at contracting the second issue provisions and car provisions surrounding carve outs and exclusions. Right. So what I don't like is seeing vague terms in these contracts.What I don't like is seeing carve outs that conflict with benefit coverage language. What does that mean?For instance, let's say a contract is carving out doula services or some type of behavioral service or some kind of service that should be typically provided in, in that professional outpatient contracts or some kind of service that should not be carved out, let's say, from primary care.So what I'm saying is if the patient's benefit requires them have access to a certain type of care, the carve outs cannot be conflicting with that benefit coverage language. Technically, and to the extent to which they're conflicting, you can push back with the payer, but you need to know that's what's, that's the issue.So when you're seeing vague terms, control f your contract and see if you find the words experimental with no reference source. Right. Experimental according to whom? According to Megan, is it according to Whitney, is it Alex? According to whom? Right. So that is important.Don't accept experimental like I experiment time to time with things. Right. But where can you find what is experimental, what isn't? So that's important, especially depending on the type of services you're covering.And if you're seeing this issue, do an addendum or an amendment, talk to your bill contracting folks and make sure that you don't see very vague language, like experimental. So in an event that there is carve out, like behavioral, we know it's carved out, right.Carillon or whoever, you need to make sure that you know who the carve out is. Right. So that is something that folks overlook a lot.But I want to make sure that you're looking at the carve out and exclusion language Provision three, coordination of benefits.Everybody here probably knows this best, but what I don't like is language when I see Plan shall coordinate benefits in accordance with its standard coordination of benefit policy. Now can someone on this call tell me what that is? What is your standard coordination of benefit policy?It's a rhetorical question because nothing in here indicates according to what standard coordination of benefit policies, what standard, how often does it change? Right. So that is important to pin down. What's important is that you look at state law and that state law trumps the payer's language. Okay.So primacy determined by state law. You could literally just say this on the phone or in a letter and make sure that you are pushing back to the with the payer.I need you to build a dispute timeline that's in accordance with the law and that you're enforcing it. Right.I was at Humana when I was contracting a network management and about 90 or so percent of providers would never push back on what we would do to them for a number of reasons, including bandwidth, including them not knowing the issue, including us sending letters to an address that is not tended to or is a service address, not a mailing address. And the payers are okay with that, especially if they report to Wall Street. You need to advocate for yourself.That's why I'm providing this structured way of auditing the language at the contracting side. So your workload could really focus on what it is that is a billing problem versus a contracting issue.The three points in this coordination of benefit provision one, primacy rules differ by product line. A Medicaid patient has a different primacy rule versus a Medicare patient. Look at the state law.If you have questions, reach out to me and I'll help you find the exact language.If there is no guidance for dual coverage scenarios, then this language of coordination of benefits are going to be conducted in accordance with the standards of the health plan. It already starts to allow a lot of room for you to have a lot of issues. So what happens in your data is what you'll see is payments withheld.While payers argue it's not my responsibility. Send it to whoever other payer. Provision 4 you might be surprised.I've seen in contracts that the payers sometimes use authorization and notification interchangeably or don't even define what is a notification versus an authorization. And these requirements are buried in exhibits. If they're in there, by and large they will be on the health plan website.Again, if you have the power to negotiate it. I would put this in the contract.Anything ambiguous or expand its scope that talks about notifications and doesn't provide a good faith platform to do contracting relationship for retrospective denials to be re adjudicated, that is a problem. So when you see providers shall obtain authorization for all services designated by plan as requiring authorization, that's an issue.What are all the services, are they going to change today, from tomorrow, from the day after? This is not something you can manage. It's not tenable. What you need is a list as an exhibit with 60 day notice when it changes.And it's against the law to do retroactive denials of an issued authorization. How many times does that happen?It's honestly upsetting and it gets me a little riled up because the payer has authorized the service and then once you render it they could they deny it retroactively which is again against federal law if it's a government funded product. And the fifth here is essentially timely filing.I see this all the time where the payer will have a certain timeline in their contracts but the law governs separately. So if you see claims must be submitted within 90 days of service. Well, for instance in California Medicaid allows 365 days.This is not acceptable, but it is acceptable for commercial patients. What I would do is go back and say 180 days for commercial membership and other membership according to law. Okay.Or the greater of timeline set by regulation, applicable regulation or. Or 180 days, whichever one is greater. Fix submission and confirm contractual windows and exceptions.And if you see any such language here as I've red flagged for you, push back. Especially if you haven't signed a contract yet. It says 90 days is the time defiling. But state law says 365 days is allowed for Medicaid for example.So please push back on that. So what's the failure modes here? 3 Points, different clocks for different time of different processes of claim.Click correcting a claim, appealing that denial potentially. And there are short windows that really do ignore provider constraints and you should push back. So what is the audit framework?I want you to do the audit in three phases and you can't possibly do it with every. Especially if you have a high volume operation there.What I want you to do is look at where you're getting the highest leakage, so where money escapes the fastest. And that's going to be the fee schedule, authorization and coordination of benefits and then the high volume services.Let's say you do, I don't know, 30,000 vaccines. They don't really each, each vaccine administration doesn't really pay that much.I've seen as high as $23 and as low as 2 or $3 per vaccine administration. But if you're providing tens of thousands of such vaccines, that really adds up. So I want you to look at where the highest dollars are.Bucket, one bucket to the highest, highest volume service sets and then look at the high friction areas. Like how many times are you getting appeals and reconsideration. These are the timelines I talked about, right?Looking at the recoupment terms, can the health plan come and take money away 18 months after or 12 months after? Recruitment periods are critical.If you were to essentially pull up a PDF contract and control F to search, you will find you could type in frequency, you can type in days. So if you control F, D A, Y, you can see where all your timelines are and start to break them down into. Okay, is this a timely filing timeline?Appeals and reconsideration timelines. Let's say we're doing this together. If you were to look at these provisions and this is essentially high leakage risk we're going to identify.I verified that effective date language is ambiguous, including updates. I see that all the time. I see that timely filing windows are not aligned with law. This is the checklist basically you guys.So any new contract or any existing contract should go through this checklist so that you can identify the risks involved with that contract and get ahead of it. So here you can see I selected three items and this is potentially high leakage. Contract part three denials and routing.Let's say based on the categorization I just showed you, there's two types of. There's three types of denial categories, right? Again, we're focused on the contract base here.So any medical necessity, level of care denial, this checklist may help you with it, but that's not what it's designed to do. Administrative. So if it's not a clean claim eligibility or missing information, timely filing, etc. Again, not the major discussion.The timely filing has to be dealt with at the contracting level. So contract base, who's the owner? Contracting and payer relations.You should be able to manage that expectation using the tools we're discussing today. And if not, then you bring out compliance people. It could be the contracting people.You simply in your letterhead you could indicate the compliance concern. This is the anatomy of an underpayment. You keep seeing a systematic underpayment on a high volume service line.The fee schedule exhibit is not matching with the adjudication rules and the fix is an amendment. You guys, an ongoing monitoring for you to immediately put this into action.What you want to do essentially next 30 days, pick your top two payers, run the checklist I shared with you and then start to renegotiate those provisions. Oftentimes I'll send a termination letter with intent to renegotiate. But if that makes you nervous, then first send intent to terminate letter.Again, depends on your market power. But I would strongly urge you to renegotiate these unfavorable terms in your contract.Or not even sign them in the first place unless they're adjusted simply because. Why have your hairs go gray when contracting needs to fix the problem? Why the cortisol when contracting should fix the problem?And I find oftentimes it's the tools that are missing for systematic review from the contracting folks. Here are the three things. If you remember nothing from this discussion, these are the three things I need you to take away.Contract language determines adjudication outcomes. Most billing fires are preventable upstream the contracting people.And doing a lightweight audit and sharing those results with contracting team is really going to help you streamline your day to day experience. Let us frame our day and our week with the greatest level of success to be had based on the tools and and the camaraderie that you have access to.So thank you everyone and I wish you the best of days. Thank you for attending today. Thank you. Bye bye everyone.