Nurturing Payer Relationships: Getting Your Just Desserts - Part I


It’s a lot of work to implement change, but poorly run practices are also a lot of work.

- Judy Capko, Capko & Company

The Big Players

In the world of practice finance, there are four major parties: the physician (that’s you), payers, patients, and staff. Often physicians feel that they have little power in this dynamic, that they’re too small to compete with payers, or that they’re at the mercy of the patients and employees that walk through the office doors every day.

There is some truth to this reality, but you must never forget that: everyone needs a primary care doctor. Your employees rely on you for the salaries that pay their bills. And yes, payers are most likely much larger than your practice, but without you submitting claims to them, they make no money.

You must understand that you always have power. How you use that power is up to you. If you want to leverage it effectively, you must analyze yourself.

Know your strengths and analyze your economic needs

What does it cost to see a patient? For those that have not taken the time to work out the exact number, here’s a quick calculation. Divide your total yearly by the number of yearly patient visits (eg, $485,772/5,067 visits = $95.85). How does your overall reimbursement rate match up with this figure? Can it be improved?

Options for Improving Reimbursement

Just the facts

  • 30% of claims in US are denied, of that 15% are never resubmitted
  • Approximately 11% of Medicare claims are denied (40% are never resubmitted)
  • Per Medicare data 65% reviewed on appeal result in increased payments
  • Experts: 75-80% of appealed claims are eventually paid

First, understand that there are things you cannot do (eg, start coding higher to get paid more), then focus on what you can do (eg, evaluate reimbursement, analyze payer performance, examine your coding accuracy).


As stated earlier, payers have a lot of power in this financial relationship, so if you are going to negotiate with them successfully over reimbursement, you must nurture your relationship.

Get familiar with provider relations - make an effort to know the representatives by name. The better your standing is within the company, the easier it will become to get the things you need.

Implement a formal quality improvement program: All the sweet talking in the world won’t help you if you are a hassle to the payer. A quality improvement program will:

  1. help you submit accurate and timely records, eliminating work on the payer’s end; and
  2. demonstrate that you provide value to the payer (more on that below).

Make reasonable requests: Ask for the world and you’ll probably be listening to a dial tone. Ask for higher fees on five to 10 codes based on utilization (backed up with data obtained from your practice management system.

Be flexible and congenial: Act according to the Golden Rule. You hate bad customer service, but that doesn’t mean you can be a bad customer. The payer should feel good about working with you.

Prove value

As you would use data to reinforce your request for higher reimbursement rates, data can help you measure, achieve, and report on outcome measures that the payer views positively.

Show the payer that you are maintaining good patient access; monitoring compliance; establishing and implement preventive measures/services. If data can help you demonstrate that your efforts are increasing patient satisfaction and resulting in fewer emergency room visits and hospitalizations, they will see that you provide them with added value, which, in turn, will increase your ability to negotiate with them.

Your staff’s role

You provide patient care, your billing staff manages the money, and accordingly, should make the process of collecting revenue as easy as possible. We’ve discussed many back-end issues, but it is also important to focus on the front end.

This centers on communicating patient responsibility. Don’t leave it to your patients to volunteer any information. They may, they may not. Ensure that your staff knows each patient’s responsibilities at time of service before they walk in the door.

Your staff can go online to quickly verify a patient’s benefits, and all balances, day-of and previous, should be paid at time of service. Timely updates of patient information will ensure that all files are accurate and speed this process dramatically.

Click here for Part II

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