What would you tell health plans if you had the chance to talk to them in person?
Typically, participating agreements between healthcare providers and payers include requirements for a Joint Operating Committee (JOC) meeting, as an opportunity to address and resolve contractual and relational issues between the parties. The premise of the meetings seem noble: By including members from both parties at the table, JOCs are designed to reduce disconnects between payers and providers; eliminate unnecessary delays in patient care and associated costs; and maintain patient outcomes and satisfaction.
But these opportunities for candid conversation often are wasted by inefficiencies. Providers, who stand to gain the most from these meetings, will often complain that they simply provide a forum for insurers to condescendingly lecture them about the provider’s failure to follow the terms of its agreement with the health plan.
It doesn’t have to be that way. Indeed, with a bit of preparation and planning, providers can leverage the opportunity provided by JOCs to bring about meaningful resolution of large-scale concerns.
Schedule regular meetings.
Because they have the most at stake, providers can — and should — take charge by scheduling the meetings. JOC meetings can be monthly, and sometimes quarterly, depending on the number of claims to be resolved and the medical practice’s revenue cycle.
From a healthcare provider lawyer’s perspective, JOCs are of noticeable significance at two points in time: First, just prior to filing of the lawsuit or the required notice of dispute. Second, immediately after resolution of the filed demand. In practice, each and every meeting is an opportunity to address needless appeals and litigation. Always insist, however, that the parties have a JOC post litigation to preclude future actions.
Set the agenda in advance.
JOCs are often regarded as a forum to address trends only, rather than any particular denied claim (or even series of related claims denials). In managed care industry practice trends are viewed as issues caused by the providers. It is incumbent on the provider, therefore, to make clear in advance that outstanding claims and other issues will be discussed, and that the payers must come to the meeting prepared to resolve the problem.
Arm yourself with data.
Providers need to prepare for the meetings carefully and establish upfront the key performance indicators that will be reviewed. Are the denials a breach of contract? Are there processes or criteria that are precluding payment of claims? Are A/R days going up or down? Be prepared with data to support your point of view.
Again, be prepared to show payers the numbers and the real effects of unfair denials. Share the data in formatted, easy to read spreadsheets in advance of the meetings so that the insurers understand the issues at hand and will come prepared to discuss and resolve them.
Make sure the right people are present.
The structure of the JOC can vary, but the health plan’s representatives usually consists of network and contracting representatives. On behalf of the provider, members from the patient accounting office nearly always participate, as well as representatives from Case Management, Coding and Billing, and may include any revenue cycle or hospital executive staff. When the hospital presents denied claims for review — and it should insist on this as a topic of any JOC — the health plan must bring representatives with settlement authority.
Set clear expectations for payer participation. It is important for the provider to ensure that the right people are at the table. By setting the agenda in advance and clearly communicating desired outcomes, the provider can help ensure that the payer send representatives with the authority to resolve claims disputes and any other outstanding issues.
Get in front of ongoing issues.
Seek to identify and anticipate trends in denials that can be avoided with proper planning. Some may be simple: For instance, the failure of the health plan to acknowledge receipt of concurrent clinical information may stem from the provider’s inability to fax information to the managed care payer’s case management office. Fax lines can be busy, and payer staff may not be available to issue prompt replies confirming receipt of the clinical information.
Or, a payer may propose that it be allowed access to a hospital’s EMR — with the assurance that it would never therefore deny a claim for lack of clinical information. Perhaps the managed care plan can create a HIPAA-compliant server with login credentials for the facility. (For a large hospital system, this could mean the elimination of over $1million in claims denied for lack of concurrent clinical information.)
Managed properly, JOCs provide a valuable opportunity for providers and payers to resolve claims and improve processes. By taking the lead in scheduling the meetings, setting the agenda, providing the data, and insisting on senior level participation, providers can turn the meetings into productive, meaningful engagements that benefit all involved.
Gustavo Matheus is a member of Anderson & Quinn, LLC, in Rockville, Maryland, representing hospitals, medical practices, nursing homes, and outpatient centers with exceptional legal and denials management services. www.andersonquinn.com.
