How To Manage And Audit Your Insurance Contracts With Connie Ziccarelli Of Guidepost Consultants

In some circumstances, and to their detriment, PT owners can unknowingly be inappropriately reimbursed for their services due to mistakes in the insurance side of handling claims. OR insurance companies can change how they process CPT codes while owners and providers are unaware, until they see a handful of denials. In this episode, Connie Ziccarelli , the Founder of Guidepost Consultants , talks with Nathan Shields about how PT owners can properly manage and audit their insurance contracts to stay on top of the contracted fee schedules and ensure proper reimbursements. Her 30 years of healthcare business management experience provides a huge value in today’s conversation. So, what are you waiting for? Tune in to this episode with Connie now!

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I’ve got a returning guest, Connie Zicarelli. Connie, it’s been a couple of years since we’ve had you on the show. Those who are new to the show, go back and tune in to our conversation about leadership that we did back in 2021. Connie is the Founder of Guidepost Practice Management Solution. She consults physical therapy private practice owners across the country, and it’s great to have her on. Thank you for joining me, Connie.

Thank you for having me back.

I’d love that you reached out to me because I don’t get a lot of feedback on the show. I hear once in a while, “I appreciate the show. I love the value.” It’s good to hear from the audience. You were an audience who was also a previous guest who said, “I tuned in to a show episode and I want add something to it.” 1) I appreciate you tuning in. 2) I appreciate you not just tuning in, but also saying, “I have something to say and I’d love to share it with the audience.” Thank you for doing that as well for taking the next step. Let’s talk about it. Which episode led you to reaching out to me?

I’m not sure quite of the number, but I can tell you the topic. The topic was with you and Adam. You all were talking about how hard it is and the squeeze that is happening in private practice trying to get reimbursement, visits, units, and upfront collections altogether, and how you have to watch all of these tenets in order to have a healthy bottom line. I found it very engaging. I was taking notes and I started to think about all the places that revenue comes from or all the way revenue comes into a private practice. I started making a little notepad.

One of the blaring things that stuck out was this area of managed care and your contracts with third party payers. I’m working with practices on looking at their contracts, looking at fee schedules, looking at adjustment rates, and also investigating Explanation of Benefits or the EOBs that come back from these payers. There are gaps. If we are not watching that, then we could be missing revenue.

We could be having our third party billing company, if you outsourced your billing company, not bringing it to your attention and having a way to cure it, or we might be missing strategies that therapists need to know on the floor on how to better document-encode for maximum reimbursement. It all starts with that managed care hub. I thought adding this to your discussion of how you have a healthy bottom line would be quite interesting to dive into.

To be clear, is that something that you do as a service for owners is to help them navigate those contracts? Is that something you simply guide them on? Do you say, “Get me that contract so I can review it?” Is that a service you provide?

Little of both. I’ve been speaking at it at conferences, and then private practice owners have been reaching out. I’m doing a hybrid. Some want to learn how to do it themselves and some say, “Give me the bottom line and then train my people.” They give me the contracts and I go to work. I am elbow deep into this kind of audit. It’s also a great element that is part of your compliance plan. One of the seven elements of a compliance plan is to audit your contracts, to audit your billing, and to audit your reimbursement. This checks that box off too.

That’s one thing when a physical therapy owner, and this is probably true for most small business owners, they open their clinics in our case. That’s one thing where, correct me if I’m wrong or if you’ve seen it differently, majority of owners would say, “I didn’t know I had to do that. I thought I signed the contract and that was it.” I would go further and say that if a buyer wanted to come or wanted to buy their practices and they said, “Let me see your contracts,” a majority of owners would say, “I don’t know where to find those. I don’t know exactly where those are.”

We’re not like that. We’re knee-deep in treating, guiding, leading, and KPIs. You name it, all the stuff that Nathan Shields tells me to do on the show. One thing that I haven’t covered on the show is managing our contracts. That’s why it’s awesome to have you on. Where do you tell an owner to start? Let’s say they have 12 to 15 contracts that they should be “actively managing.” Most contracts, can they get a paper contract from their insurance carrier if they wanted to? Are these all online on a cloud somewhere or some kind of portal? Where does an owner start to find the contracts?

I’m seeing it all over the board. I have some that can put their hands right on their contracts and they have preserved them nicely. Some are like, “I could not tell you where to begin to look.” I have some private practice owners now that acquired their business from another physical therapist and they never even asked at that acquisition time. I helped a physical therapist go through a sale and that was one of the first things they’ve asked for, “Let’s look at your contract and let’s look at your fee schedules.”

No matter where you are in the cycle of your career or the cycle of your practice, it’s going to be important that we build this department. The very first thing I do is I ask for a payer mix. That’s out of your accounts receivable report. I want to see what the ranking is, what plans you are getting most volume from because I start with the most to the least, the one that has the most volume, then work my way down.

We identify maybe the first 3 to 5, depending on how many contracts you have, and then we go find them. If you don’t have them, you can call for them. It will take repeated calls, but they have to supply it to you. I’ve done everything from going to a provider rep. I have used a provider rep from another state to get me a contract in another state. I pull in some favors if a practice owner can’t get their hands on them, but 9 times out of 10, they’re successful with a couple phone calls to get a copy of what contract is in play.

If an owner has a credentialing service, would most credentialing services have those on hand?

If they helped you with the contract or negotiation, then yes, I would say they would keep it. I would hope they would keep it. That would be an outlet as well to try.

If you negotiated this contract outside of the credentialing service, they probably should or don’t have that contract on. I like the approach in that. It’s one bite at a time. Let’s not try to get all of your contracts within the next two weeks. Let’s get 1 or 2 here in the next couple weeks and make the calls that you need to make. Obviously, you understand the audience. These are a bunch of owners that might be treating full-time or even treating part-time and have a lot of other duties outside of that. Let’s start small and go from there so that they can know that they have their contracts on file. Do you find that most contracts are paper or are they mostly electronic nowadays?

They’re sending them to you like an electronic PDF. You could either download it or save a digital file. I personally like both. I want to have a paper copy because that can be my first source. I can flip through it real fast. I print them when I get them. I want to circle all of the places that I have to go back and look at, but then of course you would save it as a digital file for posterity. Even though they’re evergreen, they’re evergreen as far as the date that they renew, but they’re not evergreen with what fee schedule you’re on now.

You could have signed this several years ago, but the fee schedule’s been vastly changed since then. Will they send that with you as part of that contract or is that a separate request?

You would have to request it at the same time. Most fee schedules are posted on payer portals. That might be an easier grab. At least we could start the audit with the fee schedule and EOBs while you’re working and waiting on the contract.

Most fee schedules are posted on payer portals.
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When you’re working with people to organize this department, you’re going to start with 1) Asking for the contracts, 2) The appropriate current fee schedule. You want both of those things. Is there anything more you’re looking for outside of that?

I always get the current CMS fee schedule because a lot of payers base their reimbursement off of CMS or at least CMS’ relative value system. I want to have that as my benchmark for that locality or for that area that I’m looking at, so that I at least know what my spine is to judge how a payer is, first of all, paying a CPT code or valuing it. That they’re at least valuing it the same as CMS would.

If you want that CMS fee schedule, you can go to the intermediary for your area.

CMS.gov , then you scroll down to your locale, and print away.

You’re looking for the fee schedule. What are the next steps? After you have some contracts, you’re procuring those with the updated fee schedules and CMS, next steps?

It depends on how deep the practice owner wants to go. I like to start at the beginning. Where’s the contract? How do we look online? Is our clinic even listed on the portal? Is it listed accurately? Are our therapist on there? Are our specialties on there? Can patients go to the portal and get the exact way I’m listed? If you haven’t updated or looked at your portal, I encourage you all to go online and look what your patients look at. Go to Humana.com and see how you look to a Humana person. That’s how deep I go. I start with every component that the practice would need to double check when it comes to how a patient will find you, how a claim is paid and processed, and then how utilization is managed with the contract authorization.

I would start at the directory, then I work my way down. I make sure that we have the checks coming to the right bank account. We’re not getting them paper, we’re getting them electronic. We change them to electronic if they’re paper, then we’d start pulling EOBs, and I do a sample a quarter. If I was doing an audit now, I would look at a sample from Q4 of 2022, Q1 of 2023, Q2 and Q3. I look at the EOBs and I compare that to what I’ve agreed upon to be paid or what the fee schedule is. I find any variance.

How often do you find a variance?

A lot more than you would think.

Really?

Yes. In fact, I’m proud to say I help a practice find 8% more money that we got to resubmit the claims for the previous year and all of that got reimbursed because they were paying at the wrong fee schedule. It happens a lot.

I’m a naive owner. I’m expecting them to follow the fee schedule that we’ve agreed to, yet they could change it at any time. Correct me if I’m wrong, but I’m not getting announcements of the fee schedule changes.

No.

They just happen. Is that right? Am I wrong? Am I missing a letter somewhere annually? Is that how it goes?

Their burden of acknowledgement to change a fee schedule is that they can post it on their website. If we’re not proactive as practice owners and we’re not at least having some radar that says, “Every quarter, let’s go look.” Just like you would a CCI edit, the Correct Coding Initiative, that’s changed every quarter. Most quarters, it doesn’t change. On the quarter it does and you don’t follow it, you’re going to get denials. That’s the way I feel about fee schedules. They can change it. If we don’t at least have some once a year or twice a year or whatever that comfort level is for a practice owner to go double check everything to make sure they’re paying, then it’s our burden.

You will get denials if we're not proactive and practice owners don't have some radar.
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It sounds like that’s where it is. We have to make the extra effort. It’s one more thing we’ve got to do.

I like to eat an elephant one bite at a time. I look at how many plans. I would recommend that you look at how many plans you want to audit, maybe it’s 6, 12, whatever that is, and divide it by 4 quarters of the year. Every quarter attack a couple. Now, you probably would not have to look at that again until the next year, but at least you’re having your team or somebody that is maybe assisting the practice owner, maybe an administrator, or at least requesting it from your third party billing company to send you EOBs so that you could do a quick proof. When a chart gets audited at a payer, they don’t ask for every patient. They ask for a sample. I do this the same way. I get a sample.

When you say a sample, maybe 3 to 5 EOBs from a single payer?

Three to five patients because I want to see their plan of care. If this plan is 10% of your practice, maybe we start with 10 charts. Let’s look at ten. If we find any variance, let’s go to 12, let’s go to 15. You then take it one step at a time until you know you either found a billing pattern or you found an issue that we need to address.

We’re looking now not just at mistakes that the insurance company may have made in payment to us, but now we’re looking at how are the providers billing and are they adjusting accordingly to how the insurance company is paying. We’re also assessing the billing collections team while these got denied. Now, where are the payments? What was your appeal process? You’re looking at a couple of other things. It’s not just for the sake of assessing and making sure that the insurance company is paying what they’re supposed to pay according to the fee schedule that they’ve posted online gratefully. Now we’re also assessing how is the billing and collections team doing with these particular claims and are the providers adjusting accordingly?

That is very correct. Also, I’m looking for any coding variances. You’ve got your coding pairs you might have to be looking at where you put the 59 modifier on, but I found some payers that aren’t paying certain CPT codes. You go back that up and you say, “They don’t have this on their fee schedule because they’re using a fee schedule from years ago and this code came in 2022. If we don’t know that, we’re excited to use the new CPT code, but the payer hasn’t caught up with us.” You know what? They write it off too. The discount comes through as a CO-45, which is a contractual write off. If your billing team isn’t sharp on their coding as well, they’re going to strike their pin to that and it’s going to go on your adjustment report as a contracted discount.

You’ll never see it.

You’ll never know.

That’s the thing. There are these little adjustments between each commercial insurance company, and I’m talking from years ago. One company would never pay 97535 the same time you’d bill 97140. If the providers weren’t aware, they would keep billing 97140 with the 97535 and it would get written up. There’s nothing you can do about it at that point. It’s at that point where the billing collections team needs to be reactive in this situation to say proactively in the future, “Don’t bill 97140 when you bill 97535.”

My friend did this the best, Mark Moore. I have to give him credit. He has a billing cheat sheet of his top 12 to 15 insurance payers. The little changes that you have to be aware of, this is for the providers, so that you don’t bill this, you can bill a re-eval code here, but not here. You can do this instead of a re-eval code. You can’t bill 97140 with 97535 on this. You need to have that understanding between billing collections and provider teams. If you’re not assessing it, then you’re throwing all these charges out hoping some of them stick.

Tuning in to the last episode that you did that I tuned in to with Adam, that’s where you guys were also talking about looking at charge per visit and making sure that your units are there. You could be throwing all of that, hitting that KPI, and reimbursing and rewarding your providers for hitting that KPI. However, it’s this hand that gets the money. If we’re not watching that, we’re going to be busy going out of business.

We’re getting our KPIs.

Why am I not making it making money? When people say, “My reimbursement per visit keeps going down,” instantly, the first thing I do is go, “We need to audit your managed care payers, we need to look at your adjustment report, and we need to get your fee schedules going.” Those three tenants make up reimbursement per visit. As adjustments go up, that CO-45, that contractual adjustment, reimbursement per visit goes down.

Do you see this discrepancy where there’s a denial? There’s a CO-45 for a particular code with a particular insurance company. Do you see that lack of communication more so with an outsourced billing company? Is there a trend or do you see it pretty normal across the board, whether billing’s in-house or outsourced that they’re not paying attention and they’re writing off least amount of energy expended possible and post the claim as is? Is that what you’re seeing?

I’m seeing it across the board. I saw it take a spike when we went to auto posting. When the software companies came up and said, “We’ve got this great thing where we’re going to post this money or this bot is going to post money. All you have to do to is approve it.” At that point, we weren’t examining it maybe as closely as we should have is when we were manually having to put in this payment because when that comes through, the auto posting is going to see CO-45 or N1-13 or whatever those antsy codes are that say it’s part of a contract and they’re going to say it’s okay.

It’s just a write up.

If you are not challenging it as the person that approves it, which I can’t plug enough that your administrators, your third party billing companies, and everybody have got to be on top of their coding and be on top of denial management, that money, you’ll never know it was there because it will be gone. You can’t go back. You would have to do an audit of every chart for every visit to even see if you could even recoup it. Which is why I say these audits are so important.

When you find those write-offs, CO-45 or some of the ones I explained, is it impossible to go back and appeal or just super difficult and time consuming?

It’s going to depend on what we find. In the example I opened up with, it was written off to contractual, and then when we did see that it was a fee schedule that did not pay according to fee schedule and we did do the resub, those got adjusted.

That was worth it.

If it’s a denial or a write-off that you need to challenge the contract because maybe the fee schedule is the example I used few years ago and we want to use 97129 and 97130, but it’s not on those fee schedules, then you may have to go back and get that into your contract or work on getting that paid, which is a higher level than resubmitting a claim.

Is it a lot of effort to change your fee schedule at that point to show these new codes?

No, that’s not hard at all.

That’s not too difficult. They’ll work with you on that kind of stuff?

They’ll work with you on that or at least tell you a timeline of when it will be available. Now, you make a decision on the floor. You make a decision as a practice owner, “What are we going to do with this service?”

How do we adjust?

To me, I call that now, we go back and we talk about it as a clinical team and say, “Here’s the issue. How do we want to now do our plan of cares?” At least we’re making an educated decision versus just writing money off. We still may want to do it and that’s fine. I have a clinic that still wants to do dry needling that’s not going to be paid and that’s fine. At least you know going into it versus it being done to you.

We’re not getting paid. Now, you can make the decision, “Do we want to continue billing this code or do we want to make this a cash service instead?” At least you’re knowledgeable about it. Did we hit a lot of the points that you are seeing? Especially the things that you’ve come across as it relates to what piqued your interest in reaching out?

I think so. The only other thing I would add is looking at your adjustment report monthly, and then quarterly to see any trends. Watching that to see where your money’s going, an adjustment report says, “Somebody was allowed to take money off your books to not get collected for something.” I want to make sure that we look at that monthly and watch it quarterly with your adjustment percentage.

The other thing I encourage practice owners to do with adjustments is to start thinking about in 2024 to start having more specific adjustment codes. Meaning, if you’ve got a contract with a plan, have an adjustment code that is for that plan, so you can start watching how much is billed to that plan, how much is paid by that plan, and then how much is adjusted off for that plan. When you go to renegotiate, you’re going to want to know those numbers. If you want to go talk about your contract, you’re going to need to know, “How much money did I give away? How much money did they take off of my fee schedule?”

I would encourage everybody to look at their adjustment code. Don’t have 3 or 4 of them, have many of them. Train your team to say, “If it’s written off for this reason, I want it to this code.” You can track your hardship, you can track your contractual adjustments, you can track many things to know and watch because if those come out of line, you know exactly where to attack to bring it back down.

That’s something I’ve never done before. I never assessed my adjustment report. We did, in very general terms, assess collections versus charges on a monthly basis. We looked at that percentage. We didn’t look at the percentage by insurance payer. When you’re talking about adding codes to these adjustments, that’s something I’m assuming most billers would be comfortable and know how to do because I don’t know if I can manipulate an EMR system to do that myself.

I’m assuming that you’d have to work closely with your billing collections team, whether that’s in-house or outsource. To develop some of these codes, your billing collections team might need to tune in to this episode if necessary. Also, to put those codes in place and put them in place by payer. That’s something I would assume then, and would you assume also that the billing collections team would be comfortable doing and know how to do it?

Yes, because most of your software out there, when you put an insurance company in to bill, you can attach a fee schedule, you can attach an allowable schedule, and you can also assign it its adjustment code. It’s going back and again through an audit saying, “I want to change this one this quarter. I want to change this one next quarter.” It’s part of that audit process so that at the end of the year, you’ve got your AR being reported by payer.

You’re going high level on me there.

I guess that’s visit number three.

As you’re pulling together these contracts, you’re assessing how they’re paying, you’re doing a contractual audit maybe on a quarterly basis or annual basis. I guess if someone’s going to negotiate a contract, that’s the first place you’d recommend they start. 1) Pull your contract, pull a fee schedule, get some EOBs, make sure you’re auditing accordingly, make sure you’re billing appropriately according to what’s acceptable and what’s outside of CO-45 and what’s in the contract. That’s where you would start, right? I’m assuming you’ve negotiated contracts before.

Get some EOBs. Make sure you audit accordingly. Make sure you're billing appropriately according to what's acceptable.
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Yes.

Tell me a little bit about that process.

I always have an old saying, “Never enter a battle you’re not prepared for.” You need to be more prepared about your processes with the payer than they know about you. I definitely do that. I get the contract. I look for a couple things. I make sure that the terms of the contractor that we’re in an active contract. I pull the current fee schedule. I look at billing, so I want to see our total charges for that payer, our total reimbursement, and our total write off again, which is why that adjustment code is important by payer. I then understand the utilization processes, who’s managing my claims. Once I have all that information, I find out who my provider rep is. I make some proactive phone calls. Once I know all of that, I ask for a meeting. I don’t ask for a meeting to renegotiate rates because we’re not giving raises.

They just laugh at you.

That’s not how I enter the battle. I enter the battle with, “Our contract is coming up. We know that there are several things that have changed in the marketplace. I’d like to sit down with you and talk about our contract and the members that we serve for you.” We talk a lot about how the contract is working, how many members we’ve seen, what our volume was, and that kind of thing. The conversation comes around to payment, and then we dance around that for a little bit.

That’s on the second meeting. That’s not on the first one. The same procedures, some of the lowest payers are flat rate payers. Do you follow some of these same procedures as you’re dealing with flat rate payers? If you got a United Healthcare plan, that’s your flat rate payer, it’s been the same for three decades. Do you approach that differently?

We’ll use the word United Healthcare.

You got it because they represent all the flat rate payers.

I look at that, that you might not be able to get an increase in your rate, but if you do this managed care audit, you can start finding out where you can streamline labor and put in more efficiencies for this payer. The bottom line isn’t only impacted by more dollars coming in. It’s also impacted by how much labor it takes to give the widget. When I’m looking at day rates, we start separating out, “What is the responsibility of the payer to bill a portion of the visit? What is the responsibility of the patient to pay part of the visit?” A day rate is a shared rate. Again, if you’re not collecting that upfront, you’re billing for your $30 or you’re billing for your $25. Almost takes more money to send a claim out than what you’re going to get paid.

It takes more money to send a claim than what you will get paid.
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We then look at utilization. If you could get a day rate payer to drop some of the utilizations because you can show how you are doing your plan of cares, that right there is a win. If you can work with the payer on getting 3, 4, or 5 visits before authorizations even kick in, that’s a win. There are many ways to look at how you renegotiate with it not being about getting more money on that day rate. It’s also about controlling what we can control.

That’s a good way to approach it because we are focused on the average reimbursement rate. Maybe the average reimbursement would be a lot easier to swallow if it didn’t require hurdles of authorizations and records requests back and forth to get 3 more visits for someone who’s only had 3 visits thus far. I like where you’re approaching this. If it is one of those big hassle flat rate payers, maybe your conversations with them could be, “What do we need to do, so that we can make this streamlined as much as possible?” Honestly, it’s too much for us to continue to see your clientele if we’re going to be forced through all these hoops to get a fraction of the payment.

With your flat rate payers, it’s also important to know what is considered a day rate or a flat rate, because I have many practices that are dual discipline. They have PT, OT, and speech. Some flat rate payers, if you do PT and OT on the same day, you’re getting one rate. If we don’t know that proactively, we don’t know we have a scheduling problem. That patient needs to come four times a week or whatever that plan of care is asking so that you’re not doing dual disciplines on the same day. Doing that will increase your revenue. Looking at your fee schedules, looking at your EOBs, and looking at what’s not getting paid.

I love that we’re talking about this because it’s something that I don’t think I’ve clearly discussed with anybody in the past five years on the show. It’s something that I’m sure many owners would look at and be like, “One more thing.” It is what we signed up for when we put our shingle out. The way to approach it and the way you address it is important to remember and that is to do 1 or 2 contracts at a time. Let’s not try to handle it all this month. Let’s look one at a time.

Also, start with your biggest payers or some of the bigger payer mix, the bigger percentage of patients, because those will probably be more readily available when you’re talking about your Medicare and maybe your Medicaid. If it’s a state run plan, then it might be easier to find in your VA and TriWest and that kind of stuff. Start with some of those. Get comfortable with the processes. As you get to some of the smaller payers in terms of percentage of population or percentage of patients, then you’re a little bit more comfortable, “This is what I need to do next.” Once you’ve done it a few times, you can rehearse that and reiterate that every quarter.

Yes.

Are you feeling pretty comfortable about what you shared? Did we cover a lot of the stuff?

I think we gave more. We did amuse-bouche. We gave a good bite before they jump in and do it as their main course. I’ve been helping people do this and it’s been eye-opening.

If people wanted to reach out to you, get your support, get your advice, how do they do that?

They can reach out directly at my website, GuidepostConsultants.com or Connie@GuidepostConsultants.com. That’s the fastest way to get to me.

Connie, are you on our Facebook group?

I am not. I am probably the only person on the planet that is not a part of Facebook.

I can’t invite you if you’re not on Facebook.

Guidepost is on Facebook, so if you would like to invite Guidepost, that could happen.

Go through Guide Post and it would be great to have you on the Facebook group. Look for our group, it’s Physical Therapy Owners Club. I’ll see if you can we’ll let you into our group because people are going to have questions and I see them post every so often about contract negotiations. Recently, someone posted about how Medicare payments were being held up. He’s noticing that pattern every quarter that payments aren’t getting released for the first 1 or 2 weeks of each quarter.

I was wondering if other people were seeing the same thing. In a situation like that, it would be good to have someone like you that has some of that insight. People are asking about contract negotiations and billing and collections questions. If you were on there and saw some of those questions, it would be great to have you respond there as well.

Sure, I will do that.

Thanks for letting us know if people wanted to find you on Facebook, they can.

Through Guide Posts, yes. Also, I’m on LinkedIn.

Thanks for joining us, Connie. I appreciate you reaching out. Thanks for joining me again on the show.

Thank you for having me.

I’m so excited to bring 30 years of healthcare business management experience in owning, operating, and growing successful outpatient, private practices to you. I have been fortunate to have made my career in the business management aspect of healthcare. I have implemented excellent business practices that paralleled excellent clinical care. I understand and teach the 4 components that make up a healthy profit. Those components are quantity of visits, quality of services provided, cost containment at all levels of the business, and maximum reimbursement. With that mindset, I have been a part of launching many practices and improved existing ones.

My passion is to work alongside healthcare entrepreneurs & professionals who want their business to thrive in a David and Goliath world, make a difference in the communities and in the lives of the patients they serve, as well as have some fun along the way. If you own a healthcare business or an administrator, we need to be on this journey together.

I’ve had the opportunity to work in some of the best specializations in healthcare, these include; physical and occupational therapy, high-risk Obstetrics and Genetics, Cardiology, Otolaryngology, and Psychology. I have met and partnered with so many smart, fun, and passionate doctors, therapists, and administrators, and now I look forward to partnering with you

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