Tips on Managed Care and Credentialing for Physical Therapists

As we are all aware, managing payer contracts is an important and on-going activity. Here are some tips that are proven to help you succeed as a private practice clinician and support team.

The Managed Care team in Central Office works diligently on auditing all payer contracts. Payer contracts are audited yearly; broken up into 4 quarters of the year. Extensive audit practices assure that both the payers and the practices are in agreement with what the contract states, and ensures that payers have correctly identified the practice information for patients looking to access the physical & occupational therapy services. An in-depth look should be taken at all critical success factors that influence both volume of visits and reimbursement. This is a great way to sort out any variance, but more importantly, work to solidify relationships with payer partners.

The first place to start looking at is how the practices and professional providers are listed in the payer directories. This activity assures accuracy in on-line directories as well as paper ones. If the practices are not listed correctly, patients and referral sources will not find them as participating clinics. This also allows a practice the opportunity to update payers with new provider names, locations and/or specialty programming. Doing this activity assures that the practices have access to patients and makes it easy for referral doctors to feel comfortable that they have chosen an "in-network" provider for their patients.

There are a few other correct influences to keep in mind to ensure reimbursement. Make sure all payments are made via electronic fund transfer. Compare the explanation of benefits (EOB) received from the payer to the fee schedule negotiated to assure the practices are getting paid the exact amount expected. Should there be any variance, contact the payer representative right away to correct. During this contact audit, take the opportunity to meet with the payer representatives. This networking activity builds a stronger relationship and allows the payer to see what is being done in the clinics and get insights on what is expected in the future. Carving these inroads with the networking activities and payers will allow the payer the opportunity to learn more about physical & occupational therapy.

After finishing the audit, share the results with each member of the practice management team. It's important to be seamlessly integrated with payer rules and nuances. Having every member of the team knowing the specificity of the contact gives patients a better guest experience by being a resource on their insurance payer.