Payer Relations: Maintain working relationships

Q. What are some of the most common problems faced when it comes to payer relations?

A. Payer relations professionals face a wide range of problems on any given day, but the most common issues can be categorized under three main topics: working with Medicaid managed care organizations (MCOs), identifying who to contact at a payer, and determining the most efficient way to solve a problem with a payer. Knowing how to navigate these problems gives anyone in payer relations an advantage.

The first issue mentioned is a big one. Medicaid managed care is a model that is expanding across the country and we need to ensure proper oversight to protect beneficiary access to HME. Because of their impact on both providers and beneficiaries, MCOs need strong oversight to ensure that they are consistent in applying coverage policy and have adequate provider networks in place for all HME product categories.

Next, when a problem occurs that inhibits timely and full reimbursement it can be a challenge to identify who to contact. Maintaining working relationships with payers is crucial to making sure you have this information readily available. When you are trying to contract with a payer that has a closed network that may be more difficult. The Internet and social media is a great place to start. Searching online for specific company titles such as network manager or provider relations can be fruitful.

Finally, it is generally a good policy to try and resolve payment problems directly with the payer first. However, there are other options if escalation is necessary. Every insurer or payer has or should have someone who regulates them.  Whether that is through a state insurance commission, a department of Medicaid, CMS, or ultimately elected officials, knowing where to take a problem is crucial. Regardless of your problem, it is always a good idea to consult your state, regional, or AAHomecare's payer relations team to access expert advice.

David Chandler is director of payer relations for AAHomecare. Reach him at davidc@aahomecare.org.