Plan Participation
Having a managed care contract provides insured patient’s access to a practice so they can realize the lowest cost share obligation. It is critical in optimizing reimbursement that each health plan, carrier, network and insurer properly represent each practice and the healthcare providers of the practice in their internal systems properly to facilitate accurate claims payment and proper online directory listing.
The Provider Data Management department will generate a comprehensive and accurate roster of contracts held by the group, each individual healthcare provider and a written understanding of how contracts are accessed at the plan level and product level.
Benefits afforded from the service:
- Gives you the ability to communicate with certainty to those patients who would need to utilize their out-of-network benefits to be seen in the practice.
- Establishes better framework for classification of patients within the practice management system as well as gain more precise knowledge about reimbursement for the networks and plans with each participating carrier.
- Create a foundation from which to link employer groups with participation to foster target marketing for business growth.
- Access to online resources to streamline operations
Service provided
- Obtain effective date of the individual provider with various networks. This includes federal and state health exchanges as well as commercial and governmental payers. Provider Data Management department of the firm will query all carriers, insurers and health plans in a market.
- Confirm the manner in which the provider is participating whether group agreement, individually direct or through an IPA or association relationship.
- Identify the networks the practice did not realize they participated in as well as validate representations on what the practice believes to be their participation to include the capture of specific effective dates.
- Initiate enrollment and identification of online resources for those the practice participate to assist in streamlining workflow and revenue operations management.
The cliché of "Who's on First?"
Knowing with complete certainty the status and effective dates of various products and plans a healthcare provider participates is the foundation of ensuring proper payment for services rendered. This is why our RCM process demands this level of data. Do not leave money on the table because your revenue operation process was unable to tag a patient to a carrier and affiliated network you participate.
