Payer relations: Show up prepared

Q. How do I work with payers to resolve billing issues?

A. Getting billing issues resolved with payers isn't about who complains loudest – it's about who shows up prepared. A little homework upfront turns a frustrating back-and-forth into a productive conversation.

Know your contract

Before reaching out, review your payer agreement for denial and appeal rights, filing deadlines and required documentation. Timelines vary by plan type and can be short, so missing a window can forfeit a valid appeal. Always follow the appeal process!

Organize your issues

Sort by plan type – Medicare Advantage, commercial or Medicaid Managed Care. Within each, group by product or HCPCS code, then by denial reason. Payers respond faster to a clear pattern rather than a grab-bag of unrelated claims.

Bring the data

Have a spreadsheet ready with detailed claims data, including the claim control number and beneficiary information, so the payer's team can locate and research claims quickly.

Keep it issue-specific

Present one issue at a time with its own supporting data, especially on complex issues. Remember, the representative you are working with often is not the person researching your claims. They must forward your request to internal claims teams, so clarity and details matter.

Approach it as a partnership

Payers respond better when providers frame these conversations as collaborative problem-solving. Share what you're seeing, ask clarifying questions, and give the payer room to investigate, but follow up on a timely basis.

Know when to push back

Know each payer’s policies and ensure compliance but be prepared to push back when they are not. For example, Medicare Advantage plans generally follow traditional Medicare coverage and payment policy unless they've adopted a published alternative. If a denial conflicts with those rules, cite the specific policy and ask the plan to explain its basis for departing from it.

Preparation, contract knowledge and a collaborative approach are the fastest path to getting claims paid correctly.

Cadie McGonagill is senior director of payer relations for AAHomecare.