How Long Should You Leave a Provider on Prepay?
One common question we all grapple with is how long we should leave a provider on prepay? Watch this video to learn some of our tips related to prepay monitoring of providers and what you should do if you aren't sure how to handle a provider that consistently bills inappropriately.
Transcript:
How long do you leave a provider on prepay?
I need to caveat the answer a little bit by saying, you should know what’s going on with the provider BEFORE you put the provider on prepay. If you have detected that a provider’s behavior seems improper and has a high error rate on a post-payment basis, you may want to put them on prepay, which is very common in our industry.
Different states and Medicaid programs have different expectations and requirements, Medicare has different expectations and requirements. But the general rule of thumb is you don’t want them on a perpetual prepay cycle. Because at some point, the provider should understand why they are on prepay. Keeping that in mind, I would say about a year, maybe a little bit longer than a year, if you have justification for that.
We generally don’t want to see a provider be on prepay for years and years and years simply because you’re able to claim savings for the claims that are being denied.
Keeping that in mind, it’s really important because what you’re trying to do is improve the provider network as well. If you’ve got a provider who’s really taking advantage of your plan, maybe they need to be termed - maybe they shouldn’t be in your network. The integrity of your provider network is very important. This is one of the things that a health plan SIU can provide value by saying “hey, we have educated this provider and still the claims coming in appear to be inappropriate based on review of documents; we can’t justify the way that they’re billing us.”
Don’t leave a provider on prepay forever. Make sure that you do a fair amount of education, letting them know they are on prepay and why you have them on prepay. You don’t want to keep them on forever.
Please send us your questions. We hope you found this helpful, thank you!