Hudson Health Plan in Tarrytown, N.Y., has made an effort to educate providers about missed reimbursement opportunities, employing field staff to show how they can bill for services they might assume to be unreimbursed. Smoking cessation counseling is one focus because physicians often don't realize that the service can be billed, says Catherine Clancy, who heads provider relations at Hudson Health.
"We realized that sometimes our systems don't connect and cooperate. In managed care, how we measure quality and do things isn't always consistent with how providers operate," Clancy says. "So rather than taking on a punitive role, we took on a teaching role to help them maximize their income because when they maximize their income, we maximize our quality scores. It's a win-win situation."
Hudson Health staff analyze claims reports and denial problems, then go to the physician practices with high levels of denials or missed opportunities to do in-services on billing and revenue optimization. Hudson Health also analyzes the Healthcare Effectiveness Data Information Set (HEDIS) codes that play into the quality scores, which often dictate whether providers receive bonuses. If the HEDIS codes do not seem to be fully utilized or properly coded, Hudson Health works with the providers to help them set up effective chargemasters and improve coding.
"When we see a coder using a bad code, a code that doesn't get the maximum reimbursement for them, we go out and meet with them to help them improve that situation," Clancy says. "We want them to properly document and code for their services because that not only gets them paid what they are entitled to, but it also generates the proper quality data that we are looking for."