What does it actually cost us to manage this Payer?

A payer contract doesn’t end when the agreement is signed.  That’s when the operational work begins.

Consider everything that may be required to get a claim from service delivery to payment:

• Provider credentialing
• Enrollment and roster maintenance
• Eligibility verification
• Prior authorization
• Clinical documentation requirements
• Claims submission
• Claim corrections
• Denial management
• Appeals
• Payment reconciliation
• Patient collections

Now ask:

How much staff time does this payer relationship consume?

And more importantly:

What does that staff time cost the organization?

Two payers can reimburse the same service at similar rates while producing dramatically different administrative workloads.

One may generate relatively clean claims and predictable payments.

The other may require repeated authorization work, frequent corrections, additional documentation, and extensive follow-up.

Those differences have a financial impact.

That’s why I believe organizations should evaluate the total cost of participation when considering a payer contract.

The fee schedule is only one piece of the equation.

The real question is what it costs to earn the reimbursement.

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