With 2021 nearly in the books, let’s evaluate how your practice is going to prepare for the changes that come with the New Year. For some, this time is perfect to implement change. Many carriers change coverage, utilization and reimbursement policies during this period, so be prepared; it is always better to be proactive with your internal policies. So, here are some simple but timely things to do before 2022 arrives.

Get Organized

Create a repository that indexes all of your provider agreements (contracts) for all of your contracted insurance carriers, both refractive and medical.

• Create two sections—one for refractive carriers and another for your medical carriers.

• Find copies of your contract, and put them in the notebook alphabetically.

• If you don’t have current copies of these documents, create a form letter/email requesting your provider agreement from each carrier. Send this to the plan administrator or to the Provider Relations department. 

Do this each and every year, as your carriers typically have the ability to unilaterally change your provider agreement without notification, leaving you in the dark about your and their obligations under the contract.

Update References and Tools

If you are looking at your CPT, HCPCS, Category III and ICD-10 code books and they don’t say 2022 on them, then you need to update your references. All of the codes we use to describe the patient-physician encounter, procedures or special diagnostic testing, modifiers and patient diagnoses are all subject to change every year. The rules of how we apply or use the codes can also change, so please make sure that your reference guides are up-to-date. 

For those of you who rely upon your EHR to make all of the updates, understand that they may not automatically update. It could require a manual update, and even then you are only getting part of the information you need by simply updating the code itself. 

Analyze and Update Your Fees

While the FTC won’t allow me to tell you how to set your fees specifically, most practices leave hard-earned revenues on the table because they haven’t evaluated their fee structure objectively and analytically—charging less than what contracted third-party payers are willing to pay. Worse yet, many of you are only updating fees annually or every couple of years. 

Fees should be analyzed and evaluated at least once per quarter. Using a tool like the Fee Schedule Analyzer in CodeSafePlus (www.codesafeplus.com) automatically evaluates your fee structure and makes educated business decisions about your fees.

Increases in both gross and net income are generally realized when you pay attention to your professional service revenues. After all, it is “free money,” as you are simply increasing your reimbursements for professional services for the same work performed.

Pick Your Battles

Claim denials are commonplace in just about every practice. Understanding the rules helps avoid inappropriate denials. Likewise, learn how to use an ABN properly in conformance with each contracted plan to legally transfer the financial liability for services to the patient. If a carrier denies something that you believe should be covered, know more than they do. The more you know about the rules and guidelines, the better a position you are in to argue your case to a third-party carrier. 

Carriers generally have to follow the same set of rules we do in coding and medical record compliance. Your operating agreement governs your rights and remedies should you have a claim or dispute with your carrier. Using reference tools like CodeSafePlus to help you keep up with these things can be so very helpful in fighting denials. 

Embrace Change

Make 2022 your year to embrace the changes that come with being an essential health care provider. Stay informed by updating your resources and in-office tools to make your life easier. Have a plan to integrate and implement these changes into your practice. And most importantly, make 2022 your best year ever—as we come to realize that the most reliable constant that we have in life is change. Anticipate it, embrace it and direct it to your benefit. Have a great 2022!

Send your coding questions to [email protected].

Dr. Rumpakis is president and CEO of Practice Resource Management, Inc., a firm that provides consulting, appraisal and management services for healthcare professionals and industry partners. As a full-time consultant, he has provided services to a wide array of ophthalmic clients. Dr. Rumpakis’s full disclosure list can be found here.