Sanford says that in addition to contract misinterpretation, there was a disconnect on cycle times, particularly with hospitals. CIGNA research showed that each billing department had its own approach to interim billing. Some facilities didn’t do any interim billing, while others begin billing as soon as the patient’s information hits the system. In some instances, this caused bills to appear as though they are outstanding with the payer by over 60 to 90 days, when in fact the bills had just been submitted.
“We’ve seen lots of variation in how hospitals approach their billing cycles; understanding that is important. You have to talk the same language,” he says.
At Presbyterian Healthcare Services, a not-for-profit system of hospitals, a medical group, and a health plan headquartered in Albuquerque, NM, Vice President of Revenue Cycle David Hennigan worked with UnitedHealthcare.
“They called us and said they wanted to streamline the process and improve claims payment accuracy; that was music to our ears,” says Hennigan. After spending nearly a year working to remedy some mutual billing miscommunications, UnitedHealthcare offered to expand the project to Presbyterian’s medical group.
“Before we would allow them to embark on this with our medical group we had to be sure it was worth the time and effort; it was. They’ve been looking for opportunities with our group now for three months,” he explains.
While communication and efficiency can enhance the claims adjudication process, payers and providers will continue to look for ways to make their relationship generate more profit and less strife. “We have a symbiotic goal: to make sure the patient gets the best care possible in the right setting and the most affordable cost position. I think we have to align our goals, and to the extent that anything in the process takes longer then it should, then we need to rework it,” says Sanford.