EPISODE SUMMARY
This episode of The Claim Game marks a pivotal moment in the credentialing journey: the final initiation where you truly claim your network territory. Jeremy and Kathryn Zug guide you through the crucial stages of reviewing and finalizing a payer contract, helping you navigate the fine print that can make or break your practice's financial health. This is the stage where you transform a pending application into a legitimate partnership and confidently secure your "game piece" on the RCM board.
KEYWORDS
Credentialing, In-Network, Payer Contracts, Fee Schedule, Timely Filing, Revenue Cycle Management (RCM), The Claim Game, Practice Solutions, Billing, Insurance Denials, Payer Audits, Recoupment, Claim Submission, Patient Registration, Eligibility and Benefits, Practice Management
TAKEAWAYS
The Contract is a Non-Negotiable Review: Never gloss over a payer contract. It's a "vital" document that outlines your responsibilities and those of the insurance company.
Look for Key Clauses: Scrutinize clauses on provider responsibilities (like accepting the negotiated rate as payment in full), payer responsibilities (clear payment timelines, transparent appeals processes), audit and recoupment look-back periods, and termination rules.
A Fee Schedule is a Must-Have: You should "absolutely, positively should not sign anything if you haven't seen a fee schedule" and understand the annual updates. It's the equivalent of accepting a job without knowing your salary.
Patience is a Virtue: Signing a contract doesn't mean you can immediately start billing. Your "start date" is the official green light, and submitting claims before it will result in irreversible denials.
Organize Your Information: Utilize tools like a credentialing application follow-up log, an insurance contact reference guide, and a credentialing matrix to track your progress, document contract details, and keep all your "ducks in a very, very neat row" for future success.
CHAPTERS
00:00 Introduction to Today’s RCM Category: Contract Finalization & Start Date Establishment
02:31 Before You Sign: What to Look for in Insurance Contracts
04:24 Understanding Your Responsibilities as an In-Network Provider
08:58 Holding Payers Accountable in Your Contract
10:1 Dispute Resolution & Appeals: Know the Process
11:47 Audit & Recoupment Clauses: Protect Your Revenue
13:05 The Fine Print on Referrals & Authorizations
13:53 Contract Duration, Exit Terms & Silent Consent
15:28 Compensation & Contracted Rates: What to Know
18:12 Submitting Claims: Deadlines, Details, and Best Practices
22:18 NPI, Tax ID & More: Make Sure It Matches
23:12 You're Not In Yet: Understanding Effective Dates
25:56 Credentialing Tools That Keep You Organized
32:19 The Final Move: Credentialed, Contracted, and In Control
33:57 Case Study: The Cost of Jumping the Gun
37:26 Conclusion: Proceed with Caution, Win with Clarity
RESOURCES
Practice Solutions (practicesol.com)
Learn More About The Claim Game: Visitpracticesol.com/podcast
The Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visitingThe Hourglass Learning Hub.
Our Blog: Explore years of educational articles on billing and practice management atPractice Solutions Blog.
Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance.
Images:
Credentialing Application Follow-Up Log
Insurance Contact Reference Guide
