If you know what you're supposed to be paid, you'll have a better chance of getting it, according to a new survey of group practice relations with payers by the Medical Group Management Association.
The MGMA, based in Englewood, Colo., surveyed 51 primary-care practices throughout Colorado and included billing and payment records for 10 commonly coded procedures.
On average, practices that had access to their contractual payment schedules reported receiving on average 4% higher reimbursements than those that reported revenues only off their explanation of benefits and were unaware of their contracted amounts, according to the survey.
It's a simple matter of leverage, according to William Jessee, M.D., president and CEO of the 19,000-member trade association of group practice leaders.
Payers contract and say they'll pay according to an attached fee schedule and never provide the schedule, Jessee said. When a group will ask, without leverage, the payer may respond by offering to provide them with prices for maybe 20 codes, but not the whole list, he said.
"It's common practice," Jessee said. Depending on the group's position in the market, "a lot of people feel they don't have much choice" and go along accepting payments without ever knowing what they're supposed to receive, he said.
Jessee said good management practice dictates periodically comparing contract amounts with actual payments to check for variance, but, obviously, if physicians don't know what they're supposed to be paid, they can't determine when they're being shortchanged.
Jessee said one initial surprise from the survey was the revelation that physicians in rural practices tended to be paid more for the same procedures than their urban colleagues, but on thinking it through, it makes sense.
"It's supply and demand," he said. "If you're a five-physician practice in a rural town, you've got a lot more leverage than in the urban areas."
In addition, the survey showed independent practice associations delivered $6 more on average per code than practices not in an IPA.
"If you're holding out in resplendent isolation, you're probably getting paid less than your colleague in an IPA," Jessee said.
Satisfaction levels with payers overall was subpar, averaging 2.1 on a 4-point scale in which 1 was poor, 2 fair, 3 good and 4 excellent. Denver-area practices reported 1.92 on average.
Payers received fairly high marks for promptness of payment, but fared poorly for their handling of credentialing, contract negotiations and other communication issues.
Jessee said the MGMA used the Colorado survey as a test and may conduct similar surveys in other states.