Payment Compliance for Medical Professionals

Managed care systems

Have you ever wondered how hospitals and doctors ensure that they get paid?

Hospitals and doctors work with payment compliance companies to ensure that they get their money from whoever is supposed to be paying them. These companies handle a variety of different types of cases, all with the goal of ensuring that health care providers receive their deserved pay for treating patients, and to ensure payment compliance on the part of the companies who pay them.

Managed care review is a process where a managed care plan, which is a health insurance plan that contract with health care providers and medical facilities to provide care for members at reduced costs, is reviewed by a payment compliance company in order to ensure payment. A managed care contract is signed by all health care professionals that accept managed care, and it is these contacts that are reviewed by the payment compliance company, to ensure contract compliance by the provider of the managed care. Payment compliance companies also conduct payment reviews for all commercial payments, such as payments from insurance companies, as well as governmental payors.

Payment compliance companies also investigate Silent PPOs and Unwarranted Discounting, and ensure revenue recovery to the healthcare providers in these situations. A Silent PPO is an organization that accesses a discounted healthcare rate for a patient from a physician or hospital, and did not have authorization from the healthcare provider to do so. While normally insurance companies negotiate with healthcare providers to get lower rates for their clients, a Silent PPO creates agreements with insurance companies and accesses these lower rates for clients who are not part of the insurance plan that the provider has contracted with.

Companies that ensure payment compliance also deal with refund review, Workers Compensation payment audits, denial management, payment audits for Medicare and Medicaid, and collecting old, complicated, or difficult AR. Helpful links.

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