Bonus Episode Transcript — HBMA Webinar Recording

Speaker: Alex Yarijanian

This bonus episode is a recording of my recent webinar with HBMA, which was actually qualified for — folks did receive continuing education credits. 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 can see, 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.

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, and 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 on the hospital system side.

I then worked at Humana Health Plan as the head negotiator and network management person for the West Territories, so I got to see the health plan side too. I left in late 2018 to start this company called Carenodes, which has essentially 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 — a lot of times we'll come to RCM issues. But billing problems are not always RCM problems. 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 your contracting team.

We're going to talk about the seven provisions 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? I deal with this day in and day out — United portal, Availity portal, the health exchange, you name it — there's very little time to go investigate the contracts to see how much of it is contract problems.

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. Here's the order of issue: contract language feeds into fee schedules and exhibits, which impacts those fee schedules and exhibits. All you have is the fee schedule — but the contract language adjudicates the fee schedule, the system build, and the payer rules that come in. That's even beyond the scope of the contract itself, because the contract will read "subject to the policies that are online or wherever." So it actually changes your contract without you really knowing, unless you're keeping on top of every single payer update possible.

So 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? Non-covered denial — what are your carve-outs? Payer responsibility confusion — what is the coordination-of-benefits 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 — 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. I have templates with this language — happy to share.

I thought it might be helpful to give you examples of language I've seen in contracts that caused these types of issues.

Issue one — fee schedule, effective dates, and updates. I had an issue — maybe I should name the payer — it was a big payer, and essentially the effective date of that agreement read "effective upon execution by both parties." Simple enough. But what happened was there was a 60-day or so delay between the time we signed the contract and when the payer signed the contract. In between that time, the rates had changed, because it was a proprietary fee schedule indexed to some scheduling ability that had changed from the time we signed the contract to the time the payer countersigned it. That is a major problem, because when the effective date isn't clear, you're potentially running into changes to the schedules you initially agreed to.

So now you have to go back to contracting and 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' notice, or without mutual agreement. These are red flags. You should certainly look into these contracts when they're put into effect and see whether the amendment or modification provisions impact your fee schedule, because that's a major issue.

No process for annual rate updates — when you look at the contract, it should tell you rates update quarterly, annually, every time CMS updates, or some cadence. If it doesn't, that's an issue. If you have the power to negotiate that "time to time" language out, negotiate it out — "time to time may change this rate," "time to time may do systematic updates" — that kind of language is a major problem. Contracts with multiple product lines that aren't aligned to a single fee schedule can each change on a different cadence, and then it becomes running after the fact instead of teeing it up at the get-go in contracting.

Issue two — provisions surrounding carve-outs and exclusions. What I don't like is seeing vague terms in contracts, and carve-outs that conflict with benefit coverage language. What does that mean? Let's say a contract is carving out doula services, or some behavioral service, or some kind of service that should typically be provided within professional outpatient contracts and should not be carved out from primary care. If the patient's benefit requires access to a certain type of care, the carve-outs cannot conflict with that benefit coverage language — and to the extent they conflict, you can push back with the payer, but you need to know that's the issue.

When you're seeing vague terms, Control+F your contract and see if you find the word "experimental" with no reference source. Experimental according to whom? According to Megan? Whitney? Alex? According to whom? Don't accept "experimental" like that. What's important is finding out where you can determine what is and isn't experimental, especially depending on the type of services you cover. If you're seeing this issue, do an addendum or amendment, talk to your contracting folks, and make sure you're not accepting vague language like "experimental." And in the event there is a carve-out — behavioral, or whoever — make sure you know exactly who the carve-out administrator is. That's something people overlook a lot.

Provision three — coordination of benefits. Everybody here probably knows this best, but what I don't like is language like "Plan shall coordinate benefits in accordance with its standard coordination of benefit policy." Can someone on this call tell me what that is? What is your standard coordination-of-benefits policy? It's a rhetorical question — nothing indicates according to what standard, or how often it changes. What's important is that you look at state law, and that state law trumps the payer's language — primacy is determined by state law. You could literally say this on the phone or in a letter and push back with the payer: "I need you to build a dispute timeline that's in accordance with the law, and enforce it."

I was at Humana, contracting in network management, and about 90% of providers would never push back on what we would do to them — for reasons including bandwidth, not knowing the issue, or us sending letters to an address that isn't tended to or is a service address rather than a mailing address. 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 on the contracting side, so your workload can really focus on what is a billing problem versus a contracting issue.

Three points on coordination of benefits: primacy rules differ by product line — a Medicaid patient has a different primacy rule than a Medicare patient, so look at the state law (reach out to me if you have questions and I'll help you find the exact language). If there is no guidance for dual-coverage scenarios, the language defaults to "conducted in accordance with the standards of the health plan," which already opens the door to a lot of issues. What you'll see in your data is payments withheld while payers argue it's not their responsibility — "send it to whoever, other payer."

Provision four — authorization and notification. You might be surprised — I've seen contracts use "authorization" and "notification" interchangeably, or not even define what a notification is versus an authorization. These requirements are buried in exhibits, or, by and large, will just be on the health plan's website — if you have the power to negotiate it, I'd put this in the contract. Anything ambiguous, or that expands scope around notifications without providing a good-faith path for retrospective denials to be re-adjudicated, is a problem.

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, tomorrow, the day after? That's 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 retroactively deny an already-issued authorization. How many times does that happen? It's honestly upsetting — the payer authorizes the service, you render it, and then they deny it retroactively, which is again against federal law if it's a government-funded product.

Provision five — timely filing. I see this all the time: the payer has a certain timeline in their contract, but the law governs separately. If you see "claims must be submitted within 90 days of service" — well, for instance, California Medicaid allows 365 days. That's not acceptable for Medicaid, though it might be acceptable for commercial patients. What I would do is go back and say "180 days for commercial membership, and other membership according to law" — or "the greater of the timeline set by applicable regulation or 180 days, whichever is greater." Fix your submission and confirm contractual windows and exceptions. If you see language like this that I've flagged, push back — especially if you haven't signed the contract yet. It might say 90 days is the timely-filing window, but state law says 365 days is allowed for Medicaid, for example — so push back on that.

The failure modes here come down to three points: different clocks for different processes (claim submission, correcting a claim, appealing a denial), and short windows that ignore provider constraints — push back on those.

So, what is the audit framework? I want you to do the audit in three phases — you can't possibly review every contract line by line, especially at a high-volume operation. First, look at where you're getting the highest leakage — where money escapes the fastest. That's going to be the fee schedule, authorization, and coordination-of-benefits provisions, plus the high-volume services. Let's say you do 30,000 vaccines — each administration doesn't pay much (I've seen as high as $23 and as low as $2–3 per administration), but at tens of thousands of doses, it adds up. So bucket one: highest dollars. Bucket two: highest-volume service sets.

Then look at the high-friction areas — how often you're getting appeals and reconsiderations (the timelines I talked about), and the recoupment terms — can the health plan come and take money away 18 months, or 12 months, later? Recoupment periods are critical. If you pull up the contract PDF and Control+F, you can search "frequency" or type "days," and see where all your timelines are, then start to break them down — is this a timely-filing timeline, an appeals-and-reconsideration timeline?

Let's say we're doing this together — if you look at these provisions, this is essentially the high-leakage risk we're identifying: verify that effective-date language is ambiguous, including for updates (I see that all the time), and that timely-filing windows aren't aligned with law. This is the checklist, basically — any new or existing contract should go through this checklist so you can identify the risks involved and get ahead of it. Here, if you select three items, this is potentially high leakage.

Contract part three — denials and routing. Based on the categorization I just showed you, there are three types of denial categories — again, focused on the contract side here. Medical necessity / level-of-care denials — this checklist may help but isn't designed for that. Administrative — not a clean claim, eligibility, missing information, timely filing, etc. — again, not the major discussion; timely filing has to be dealt with at the contracting level. Contract-based — 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, bring in compliance — it could be the contracting people; you can simply indicate the compliance concern in your letterhead.

This is the anatomy of an underpayment: you keep seeing a systematic underpayment on a high-volume service line — the fee-schedule exhibit doesn't match the adjudication rules — and the fix is an amendment, plus ongoing monitoring, for you to immediately put into action.

What you want to do, essentially, in the next 30 days: pick your top two payers, run the checklist I shared with you, and start to renegotiate those provisions. Oftentimes I'll send a termination letter with intent to renegotiate — but if that makes you nervous, send an intent-to-terminate letter first. Again, it 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 else from this discussion, remember these:

1. Contract language determines adjudication outcomes.
2. Most billing fires are preventable upstream, at the contracting level.
3. Doing a lightweight audit and sharing those results with the contracting team will really help streamline your day-to-day experience.

Let's frame our day and our week with the greatest level of success to be had, based on the tools and the camaraderie we 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.