The Commercial Payor Relations Committee WORKING TOGETHER WITH PAYORS By Greg Wehrman Why I Got Involved I have been a member of HBma since the early days. However, for a myriad of legitimate reasons, and perhaps even some lame excuses, I have not been actively involved with the association for the last ten years. sure, I go to most of the conferences. I read Billing every month. I even pay close attention to the message boards and to the healthcare industry in general. However, it was not until the HBma spring Conference in 2013 that I decided to join a committee. In essence, I wanted to become involved in and committed to HBma. my decision did not come easily. During the conference, I proceeded over to the HBma booth and glanced over the list of possible committees to join. Despite my good intentions to participate, I did nothing. The next day, I was intrigued by a discussion involving a few of the Commercial Payor relations (CPr) Committee members. again, I just walked past the booth. later that day, Paul myers mentioned that the committee chair, jeanne gilreath (now our current president), was looking for more members. Finally, after speaking with jeanne, I decided to join the CPr Committee. The CPR Committee and the Major Payors getting used to being a committee member took some time. It was only after a few months of participating on a very limited level on the monthly CPr Committee calls that I even remotely understood what the CPr Committee was all about. In a nutshell, the CPr Committee meets monthly with the goal of bringing payors together to discover ways in which we can share our knowledge, educate each other, and advocate for mutual benefits. We also look for ways to promote the value of working with HBma. Various CPr Committee members have monthly calls with representatives from aetna, Cigna, united Healthcare, and occasionally with Florida Blue (Blue Cross/Blue shield). Billing Companies and Insurance Companies – Working Together after I spent some time on the CPr Committee, I came to know a simple truth: payors are like any other business. They 8 HBma BIllINg • maY. juNe.2014 HBMA NeWs need to be mindful of costs, and although they may not pay unnecessary claims, they do want to improve their operations. Therefore, most payors (such as aetna, Cigna, united Healthcare and Florida Blue) are truly very enthusiastic, supportive, and engaged in working with the CPr Committee. several other CPr Committee members and I attend a monthly call with aetna. I find that the people we work with at aetna are extremely helpful. aetna – and all of the payors we have an ongoing relationship with – is truly intent on streamlining its operations and working with us. During my work on the CPr Committee, I have come to realize that there are many aspects of our operations that payors do not understand. However, billing companies also may not realize the scope of what insurance companies do. after all, in today’s business world, cutting costs and increasing efficiencies are major factors for both of our industries. We have the same goals; we just need to educate one another on what we do and why, so we can get there together! What I Have Learned and My Personal Goals I have also come to learn more about our industry. In my opinion, denial reasons can and should be more specific. Payors need to understand that we need additional information. Too many times, my staff find the true reason(s) for the claim being denied, but only after calling the payor for clarification. The calls that my staff make cost me money, and they are also an expense for the payors. In most instances, the time spent on the phone could have been avoided. For example, one of my issues is the denial code “Not a Covered Benefit or Benefits exhausted.” First of all, I believe that no denial code should include the word “or.” These codes should instead read, “Not a Covered Benefit” and “Benefits exhausted” as two separate denial reasons. all too often after making a phone call, we find out that the “real” reason the claim “was not a covered benefit” was actually because it required prior authorization, which was not obtained, or it was applied to the patient’s deductible. The payor told me the “what,” but often not the “why” or “how” or “when.” In other words, the denial should have also had a remark code that stated, “service (continued on page 10)
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