Situation: As a doctor participating in an insurance network, you need to ensure you’re being fairly compensated for your services. Insurance companies have fee schedules that dictate payment rates, but errors or discrepancies can occur. Additionally, situations like pandemics can introduce unforeseen challenges regarding payment structures.
Solution:
- Regularly Evaluate Billing: Conduct an annual or quarterly review of your billing statements to compare payments received against the agreed-upon fee schedule. This proactive approach allows you to identify potential underpayments.
- Negotiate with Payers: If discrepancies are found, present evidence to the insurance company. Reference relevant laws, state mandates (especially during Public Health Emergencies – PHE), and any updates impacting your practice (e.g., telehealth adoption).
- Consider an IPA: An Independent Practice Association (IPA) is an alternative to direct contracting with insurance companies. IPAs often offer:
- Negotiated Rates: IPAs may have secured better rates with insurers than those available through individual contracts.
- Waivers and Privileges: IPAs may offer benefits not included in direct contracts.
Methods of Prevention:
- Routine Billing Review: Schedule regular (annual or quarterly) evaluations of your billing statements.
- Stay Informed: Keep yourself updated on relevant laws, state mandates (especially during PHEs), and changes impacting your practice (e.g., telehealth regulations).
- IPA Research: Investigate IPAs in your area, considering:
- Specialty Focus: Identify IPAs catering to your specific specialty (e.g., primary care, mental health).
- Plan Options: Understand the insurance plans offered by the IPA and if you have the flexibility to choose specific plans.
- Contract Details: Review termination rights, obligations, and any annual fees associated with the IPA agreement.
By regularly monitoring your payments and considering an IPA as an alternative, you can ensure fair compensation for your services and navigate challenges that may arise in the healthcare landscape.
Remember, this is just a guide, and you should consult with a professional if you have any specific questions about your situation. Our Operations Director, Olga Khabinskay, will be happy to assist you in understanding this matter and optimizing your reimbursements. With WCH, get the reimbursements you deserve!
Email: olgak@wchsb.com
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