Beginning January 1, the Centers for Medicare & Medicaid Services (CMS) expanded its billing policy for HCPCS code G2211 (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all…
Navigating Changes in Payer Policies
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Navigating Changes in Payer Policies
January is the ideal time to do a payer policy review. Many payers make changes and updates effective at the start of the year.
Below are steps to navigating changes in payer policies:
- Designate a payer policy reviewer
- Keep charts of payer policies for codes and modifiers
- Flag any changes to help keep everyone in the loop
- Build in billing system alerts for codes and modifiers not covered by payers
- Provide transparency with patients on services not covered by payer
Payers don’t always provide policy notice updates. To circumvent this, it can help to designate a member of your team to review payer policy updates at least annually. This team member should ensure that both the clinical team and the billing team are aware of policy changes. You may wish to discuss the impact of any changes and any necessary action.
Note: Each of the large commercial payers have their clinical and/or reimbursement policies on their website. When payers send newsletters, the policy updates are often included. It is key to review these.
Creating payer policy reference charts or tables provides awareness of which payers will or will not pay for services/procedures. Gone are the days of colored patient files to differentiate payers. So an accessible tool can assist all members of your team, from the front desk for patient registration through to billing.
As your billing system allows, build in alerts for codes and modifiers not covered by or capped payers. The alerts can help you avoid denied claims/submissions.
If your patient wants a service/treatment not covered by the payer, provide the patient with an Advance Beneficiary Notice (ABN) to sign acknowledging the service/treatment is not covered by their insurance and they will have to pay out of pocket. You may want to collect a larger portion up front too as assurance.
Still have payer issues? Need to file a complaint? Contact the insurance commissioner for your state.
Source: What’s in Your AR? with Cheyenne Brinson, BrinsonAnderson Consulting presented at 2023 AAOA Annual Meeting.
More information on navigating payer policies is available in the “Work Smarter Not Harder: Recharge Your ENT Business Practice” Education Stack available January 7 to June 30, 2025. This Education Stack offers 7 credit hours of CME/CC on core and emerging business of medicine topics.
The American Academy of Otolaryngic Allergy (AAOA) Practice Resources are intended as a guide to help AAOA members integrate allergy into their otolaryngology practice and to continually improve on this integration as new information, regulations, and resources become available.
While these tools are meant as resources, we highly recommend seeking input from your practice counsel and local/state medical associations and regulatory authorities, as rules vary between states. Each practice is responsible for confirming coverage, coding, and payment parameters for those payers and regulators affecting their practice. Our intention is to offer insights by sharing what others within AAOA do. These are not meant as recommendations.
