Q&A: Payer contracting processes

Q. How can we help ensure all hospital departments involved in payer contracting are on the same page and understand the terms?

A. Contracting, in collaboration with the finance department, should establish a payer contract summary document that lists and organizes contracts and provides contract terms and renewal dates, specific requirements, carve outs, payment terms, appeals process, agreed-upon quality measures, payer key contact information, and a glossary of definitions (to include definition of inpatient and any other information the entire revenue cycle team will need to perform their jobs).

For example, will billing have to perform special edits? The summary document must be easily available through a secure shared server or similar method for real-time access by staff to ensure the terms are met concurrently with the patient stay. It is important to have reimbursement rates on the list, as staff need to manage the cost structure to reimbursement rules. Once the patient leaves and the claim is dropped, there is very little recourse if the claim is denied and terms were not followed.

For more information, see The Revenue Integrity Training Toolkit.

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