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I’m sure you’ve heard the expression, “Garbage in garbage out” – GIGO.

We’ve seen this frequently when it comes to things like setting up payers within a billing system. Straight Medicare might list it as Medicare of Texas. I’m not even talking about the plans, just the payer itself. The billing system might have four different identical payers: One that lists Horizon, one that says Horizon Blue Cross Blue Shield, one that says Blue Cross Blue Shield New Jersey, one that says BCBS New Jersey or BCBS NJ. It’s crazy how many different iterations we’ve seen in one system of the same payer.

Save time by eliminating redundancies

Again, I’m distinguishing payer and plan: Just payer, just the insurance company. We’ve seen that. It’s widespread to see multiple iterations. It’s uncommon not to see that. I mean, rarely you don’t see many, many different instances of that.

We saw one client where they had 37 different straight Medicare plans. To be clear, this is not Medicare Advantage. They weren’t operating in 37 other states. They had 37 different Medicare names. Not plans, payers, insurance names. Straight Medicare. I couldn’t believe it, and it’s a complete disaster. It’s a mess.

Get the billing details right

How is that possible? And what are the ramifications? Well, the ramifications are this. If you are trying to bill successfully and get paid, then you want to link every single insurer to an ID, set it up for the clearinghouse, and those kinds of things so that it goes across and gets paid. That’s an infrastructure thing.

More importantly,  if you are trying to identify why you’re not getting paid or denials patterns, or analyze anything to identify some root cause problem, drill down group claims together, slice and dice, or even see, “Hey! Is our volume of Medicare going up or going down?” There is no way somebody will figure out how to make sure they find all the different 37 Medicares in the system. It’s going to be very fragmented. You’re going to have no idea what’s going on. 

So you’re not going to have good insight into your business. You’re not going to be able to solve problems. You’re not going to be able to run denials analysis or any other types of analyses if you have this giant mishmash of different payers. That’s going to lose your money. You’re going to be suffering financially.

How does it get set up like this? Well, most systems don’t come set up, pre-installed with all the payers and plans. You enter the plans yourself. Depending upon how the structure is set up, you often have a biller, a patient registration person, or whoever is in charge of entering patients at the front desk. In those instances, they can enter whatever they want. As a result,  you will see typos where somebody puts in Blue Cross with one “s” Blue Shield of New Jersey. And then, the next time they put it indifferently, you might end up with 10, 20, 30 different insurance names that are all the same payer.

Designate one person to create payers

The way to solve this problem is to lock on who can create payers in the system. So it would help if you had a superuser, who is the only person who is granted access to create new payers. Now, there’s an entire operational process around this that has to be involved, though, because if you lock it down like that, very quickly, your patient registration people, your receptionists, whomever they might be, will throw up their hands and say, “Ah, we couldn’t find Medicare, so we didn’t enter the patient.” Therefore, you’ll have a massive problem on that side. This needs to be a coordinated effort. However, that’s a separate conversation around how to organize and implement.

Segment payers right away

The key is, you can only have one person who’s in charge of the master list. They have to clean all of this up. They have to get all of these kicked out in a report. Somebody’s going to flag and group them all saying, “Okay, this one is still the same payer as this one, and this one, and this one, and this one, and this one. And these 37 are all the same payer.” So you have to group those, and then go back and make some changes.

It is a bit complex in terms of fixing all the stuff retroactively versus going forward. That’s a separate conversation. Make sure that you lock it down so that in the future, there’s only one Horizon Blue Cross Blue Shield of New Jersey, however you want to call it. And there’s only one Medicare in your state that’s straight. Not Railroad, not Medicare Advantage plan, and so on. Just straight Medicare.

Final thought

Lock it down. Get that person in control. Make sure that your software is capable of doing that. If not, talk to them, get a different system if you have to. Solve this issue, and increase profitability.