How is Your Agency Managing Varying Payer Rules for Health Insurance Providers?

July 7, 2021

As is common in today’s post acute healthcare, working with multiple different payers can be difficult, especially when an EMR isn’t configurable by payer. High administrative overhead and human errors can be common if the information has to be tracked outside of the EMR. Managing the variances associated with authorizations, charges by unit, visits, hours, rounding, invoice splitting, UB04/CMS1500 field population, OASIS data sets, change orders completion/signing across multiple health insurance providers and other payers can be daunting.

In this article, we will discuss the challenges that some agencies can face with their EMR, and how an efficient EMR should be able to configure and manage their payer rules inside their system. 

Still Keeping Track of Your Payors in a Spreadsheet? 

Agencies dealing with payers and authorizations can often become frustrated with their EMR. Unlike better software with a configurable system, some EMRs are still requiring their users to use a spreadsheet to keep track of what each payer wants or needs. Eventually, the users will become overwhelmed and extremely disorganized. How are you supposed to keep track of the units each payer has required for patients, or mandatory actions to be able to send in a claim? 

There are also certain forms (UB04, CMS1500/ HCFA1500, invoice) that have codes and services that must be filled out before being sent in. If an agency’s EMR can’t keep track of the forms required by each payer, how is an agency supposed to know which form to send in? The spreadsheet would be all over the place, and the forms are certainly going to become lost. 

Having a software that helps you keep track of health insurance providers’ rules is essential for any agency to run efficiently with reliable cash flow. Payers have different requirements which can overwhelm an agency if most of the rules and regulations are tracked in a spreadsheet. Information can become misplaced, forgotten, miss entered resulting in expensive cancel re-bill cycles or outright failure to gain remittance. 

KanTime – How Better Happens

How KanTime Handles Health Insurance Providers 

With KanTime, the agency is able to configure virtually any payer rule.. All the agency has to do is select the payer and the services being performed for KanTime’s rules engine to then guide the user. Once the services are documented as completed, the system knows what needs to be on the claim form.

Some features that KanTime can configure are:

  • Face to Face Encounter

    • Some payers require a face to face encounter to be documented between the Physician and patient before the claim can be accepted.  KanTime provides configurable options for this as it varies by payer; examples are , mandatory, not mandatory, or required. If it is mandatory, KanTime won’t let the user submit a claim until the documentation is complete. 
  • Eligibility Check Required 

    • Most times an eligibility check is required, but it can be configured inside KanTime’s Payer Setup to be mandatory. It depends on the agency if they want to make it required or not.
  • Oasis Data Set

    • The Oasis Data set is generally only required by CMS, however some agencies want to collect it for consistency, but are not obligated to send it to CMS. KanTime allows agencies to configure the data set where they can still collect OASIS but don’t have to export it to Medicare. 
  • Change Orders

    • Payer rules associated with the POC and other change orders can be configured with KanTime. The software tracks which order types that each health insurance provider requires (i.e. do the change orders need to be signed by a physician and do they need to be signed before the agency bills the payer).
    • If an auditor sees the order was signed AFTER the claim was sent this can result in recoupement. KanTime makes sure that the agency is compliant and follows the rules and regulations of the payer before releasing the claim. 
  • Authorizations

    • In KanTime the agency can enforce daily, weekly and monthly limits on authorizations. The User can put a hard stop in the system to prevent scheduling over the required visits for authorization or they can choose to employ a soft warning.
    • Configurable role permissions can control who in the agency is authorized to override when the situation merits it. .
  • Office Authorization

    • If a payer reliably gives authorization for services, but can’t give it immediately due to certain circumstances, then KanTime allows an office manager to populate an office authorization for however many visits are needed.
    • KanTime will also let the User know on their dashboard how many office authorizations are currently in the system, and that the User needs to contact the payer for the actual authorization. 
  • No Authorization

    • If an agency doesn’t receive an authorization from the payer, then the User has the ability to configure what happens next by each individual payer. A few examples are:
      • Schedule can’t be created
      • Schedule can be created but clinician can’t check in 
      • Schedule can be created but can’t be approved 
      • Schedule can be approved, but cannot be billed 
      • Schedule can be approved, billed, and payrolled
  • Enable Co-Pay

    • Enabling a co-pay in KanTime is super easy. The system will generate a claim for the co-payer and the health insurance provider at the same time. There is no waiting and the system will already know how much to charge to each party. 

It’s crazy to think that some agencies keep much of this information on a spreadsheet or somewhere that could be misplaced, to guide them in generation of claims for services rendered. This methodology will result in excessive billing department staffing, delayed cash flow and a constant cycle of cancel rebill.  

Having an EMR that is configurable by payer and role, organized, and robust can help agencies who are struggling with software that has limited or no configuration at all. With KanTime, an agency will configure the payer once and let KanTime manage the rules for them. Dashboard alerts let staff know what is ready to bill, what’s not and why. No more feeling overwhelmed and unorganized. 

For more information on how KanTime configures it’s payers, check out our website or request a demo today! 

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