Patient access should be familiar with its facilities’ third-party contractual agreements and make sure they don’t include provisions that will cause problems, urges Pete Kraus, CHAM, CPAR, FHAM, business analyst for revenue cycle operations at Emory Healthcare in Atlanta.

“The more cynical among us suspect that insurance companies push hard to include contractual provisions that are difficult for the provider to avoid, or at least delay, payment,” Kraus says.

Easily Identifiable?

It is important that contract-related claims payment requirements appear on the insurance ID card so they can be identified accurately, Kraus says.

“The requirements themselves must be manageable by patient access staff, within a time frame compatible with the scheduling/preadmit/admit process flow of the institution,” Kraus adds, recommending staff ask these questions:

  • If there are follow-up requirements, are they easily identifiable and doable within a reasonable time frame?
  • Are parameters for payer response compatible with patient care expectations?

“Access must be clear on what department is responsible for follow-up and, if necessary, have trained staff available whenever required,” Kraus says.

  • Are any “silent” preferred provider organizations involved? If so, do they apply to all admissions, or only certain diagnoses or procedures?
  • Does the payer stipulate contractual rules about what can be collected from a patient prior to service?
  • How are exceptions addressed?
  • Is there a provision for situations in which information isn’t available in a timely manner from the patient or internal/external systems?
  • What if a patient access staff member makes an unintentional error? Can the problem be fixed retrospectively if caught within a reasonable time span?
  • Are payer and facility on the same page if a prospective patient fails to meet contractual criteria and challenges the denial of coverage?

“All these variables and many others can be hidden or obfuscated in contractual language,” Kraus notes.

Ideally, the facility should standardize contractual language and provisions for all payer contracts. This way, patient access has to learn just one set of rules.

“At a minimum, the language should be sufficiently similar and stated clearly enough to avoid obscure provisions and variances not discovered until the payer denies a claim,” Kraus says, recommending patient access work closely with the facility’s contract management team on this. “The biggest problems tend to relate to unreasonable data requirements, timing issues, inflexibility, and language ambiguity.” Kraus recommends these practices:

  • Create a collaborative arrangement with the facility’s managed care department.

This allows patient access leaders to provide input to prevent contracts from containing clauses that are difficult, time-consuming, or outright impossible to meet.

Providers should reject provisions that are not in their interest, if at all possible, Kraus argues, and address those that prove unavoidable.

“Examples might include when the facility is required to notify the payer prior to or during the patient’s treatment, or provide information prior to admission that is unlikely to be available at that time,” Kraus says.

  • Encourage managed care to negotiate similar prerequisite provisions for all payers.

Even if reminder prompts to users are programmed into the registration system, Kraus says, “the fewer differences among payers, the better. This minimizes hard-to-remember exceptions to the rule.”

Encouraging a standardized approach across payers “avoids at least some unexpected ‘gotchas,’” Kraus adds.


  • Pete Kraus, CHAM, CPAR, FHAM, Business Analyst, Revenue Cycle Operations, Emory Healthcare, Atlanta. Phone: (404) 712-4399. Fax: (404) 712-1316. Email: