AMA's Private Sector Advocacy (PSA) Practice Management Center has developed the following practice tips to provide physicians and their staff with educational resources and tools to address private payer and practice management issues.
As a physician, you know there is strength in numbers. The AMA helps all physicians, regardless of specialty or practice setting, speak with a unified voice on the most important issues facing medicine. Please encourage the physicians in your group to visit www.ama-assn.org/go/membership and learn more. Visit www.ama-assn.org/go/psa for more AMA-PSA information and resources.
Please view the links below for the following:
Practice Management Tips and Products
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1. Helping patients understand their payment responsibilities
2. Mastering the claims management cycle
3. Negotiating contracts
4. Automate your practice and reap savings
5. Connecting with your patients
6. Protect your practice from inappropriate discounts
7. Health plan payer's claim edits can effect a physician's bottom line
8. Appeal that claim: taking an active approach to the claims management process
9. Selecting a clearinghouse to process claims
10. Defining a medical billing service
11. Selecting a billing software vendor for your practice
12. Collecting payment for services rendered
13. Appointment scheduling and your bottom line
14. Filing a complaint
15. Taking an active approach to the claims management process
16. Claims submission, processing, adjudication and payment
17. Losing revenue through inappropriate health plan adjustments
18. Performing an internal billing audit
19. Preparing for health plan retrospective audits
20. Getting paid what you deserve for out-of-network treatment
21. Stopping unfair payer practices
22. Combating inappropriate health plan claim denials
23. Improving practice efficiencies with electronic claims submissions
24. Electronic Funds Transfer Agreements
1. Helping patients understand their payment responsibilities
Physicians and office staff are encouraged to involve and educate patients about medical treatment decisions, as well as payer payment policies and procedures. Industry trends indicate that both payers and employers are shifting more of the responsibility and cost of health care treatment and payment to the patient. In response to this shift, physicians and office staff need to consider proactively either establishing or revising their practice's payment and collection policies accordingly.
The following educational resources, Helping your patients understand their billing and payment responsibilities 
(PDF, 324KB) and Understanding your health insurance policy and payment practices (PDF, 28KB), were developed by the AMA-PSA unit and the Kentucky Medical Association. AMA members can download these informative practice management resources free of charge.
2. Mastering the claims management cycle
The first step in the claims management cycle is to improve physician practice viability through efficient contracting. When entering into negotiations with the health plan's representative, physicians need to be well prepared. The more physicians understand about health plans, the better they will be able to decide if a health plan is suitable for their practice. The following educational resources, A guide to working with health plan representatives (PDF, 146KB) and 15 questions to ask before signing a managed care contract (PDF, 602KB) contains valuable information on managed care contracting. AMA members can download these informative practice management resources free of charge.
3. Negotiating contracts
Taking command of payer contracts and thoroughly understanding their implications is essential to the success of a physician practice. Protect your practice from inappropriate payer discounts by understanding the implications of contract provisions.
The fourth edition of the AMA's Model Managed Care Contract (PDF, 453KB) offers a reasonable alternative to the one-sided, take-it-or-leave-it contracts physicians typically receive from health plans. The contract includes 10 supplemental discussion pieces on a range of important issues including medical necessity/external review, "all products" provisions, and the restrictions and obligations that can occur after a contract is terminated. In addition to the Model Managed Care Contract, the AMA-PSA educational resource 15 steps to protect your practice from unfair payment practices (PDF, 169KB) offers useful tips.
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4. Automate your practice and reap savings
The movement by physicians, payers and vendors to streamline health care delivery through the adoption and use of information technology solutions strives to create a more efficient claims management revenue process for all involved. By eliminating significant parts of the manual processes in an office's routine, physicians can free their practice staff to perform other revenue-enhancing functions. Read the educational resource Information technology solutions: consider the potential savings (PDF, 158KB) for more tips. AMA members can download this informative practice management resource free of charge.
5. Connecting with your patients
Online medical consultations, also known as e-visits, present opportunities for growth and increased efficiency in the physician practice.To learn more about this new patient convenience and if it is right for your practice, read the educational resource Online medical consultations: connecting physicians with patients (PDF, 679KB). AMA members can download this informative practice management resource free of charge.
6. Protect your practice from inappropriate discounts
Multiple payers could be taking advantage of your lowest contracted payment rate through the use of a rental network preferred provider organization (PPO). The AMA developed the Read your contracts: Is your practice losing revenue through rental network PPOs? (PDF, 138KB) booklet to educate physicians about how to identify and protect their practices from inappropriate discounts.
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7. Health plan payer's claim edits can effect a physician's bottom line
The AMA developed the flyer The effect a payer's claim edits can have on the repricing and payment of your claim (PDF, 262KB) to raise physician awareness of how a claim edit applied by a payer could affect the physician's bottom line. This flyer highlights how a negotiated fee with a payer for a specific service performed does not necessarily translate into payment of that fee for that service on a claim. AMA members can download this informative practice management resource free of charge.
8. Appeal that claim: taking an active approach to the claims management process
The AMA developed the Appeal that claim (PDF, 2MB) booklet to simplify the claim audit and appeals process for physicians and their practice staff. This booklet can help reduce the administrative burden by delivering a step-by-step process to appeal an underpaid, delayed or inappropriately denied claim. AMA members can download this informative practice management resource free of charge.
9. Selecting a clearinghouse to process claims
Physicians and practice staff—are you considering selecting a clearinghouse to handle your practice’s claims process and submission functions? If so, you are encouraged to review the What is a Clearinghouse? (PDF, 33KB) resource developed by the AMA's Private Sector Advocacy (PSA) unit and the Kentucky Medical Association. Designed to educate physicians and practice staff about the clearinghouse function, this resource explains the nuances that relate to the submission and transmission of the physician practice's claim information by an outside clearinghouse.
10. Defining a medical billing service
Before you consider working with one, it is important to know what a medical billing service is and what they can do for your practice. A medical billing service may help physician practices save time and increase profitability by reducing billing expenses and increasing revenues. A good medical billing service also allows physician practices to concentrate on their patients while increasing the bottom line. To help physicians in this endeavor, the AMA developed the educational resource What is a Medical Billing Service? (PDF, 24KB).
11. Selecting a billing software vendor for your practice
Purchasing medical billing software for a physician practice can be a daunting task and may result in added costs. To help physicians, the AMA's Private Sector Advocacy (PSA) unit and the Kentucky Medical Association have developed How to Select a Billing Software Vendor for the Physician Practice (PDF, 29KB).
The resource provides the physician practice with a proactive approach to determining the specific needs of the practice.
12. Collecting payment for services rendered
Collection services can play an integral role in helping physician practices improve cash flow by securing payment from hard-to-collect delinquent accounts. To offer physicians guidance in selecting a service, the AMA's Private Sector Advocacy (PSA) unit has developed the resource How to Select a Collection Service (PDF, 30KB).
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13. Appointment scheduling and your bottom line
Something as simple as appointment scheduling can help improve a physician practice’s bottom line. For example, gathering basic patient data at the time the appointment is scheduled allows for the verification of the patient’s health insurance information before a patient’s visit. To help physicians in this endeavor, the AMA, in conjunction with the Kentucky Medical Association, developed the resource Appointment Scheduling to Improve Your Bottom Line (PDF, 513KB).
14. Filing a complaint
Physicians and practice staff—alert the AMA of problems you may be experiencing with health plans and payers by visiting www.ama-assn.org/go/clickandcomplain and completing the AMA Health Plan and HIPAA Complaint Forms. These forms gather sophisticated data on the types and severity of administrative “hassles” that the physician practice experiences on a day-to-day basis in the managed care environment.
While the AMA may pursue compliance activities with health plans or payers where a pattern of administrative hassles are shown, the information provided will be used primarily to shape the AMA’s agenda. The AMA does not directly respond to these complaints, as the forms are anonymous. If an AMA member wishes, they may contact the AMA Private Sector Advocacy unit at (800) 262-3211.
15. Taking an active approach to the claims management process
The AMA developed the booklet Prepare that Claim (PDF, 1,015KB) to help physician practices review the efficiency of their current internal claims management process. This booklet contains sample forms and policies that can be adapted to fit the specific needs of a physician practice.
16. Claims submission, processing, adjudication and payment
The AMA developed the booklet and wall chart Follow that Claim: Claims Submission, Processing, Adjudication and Payment to provide physicians and their office staff with an understanding of what happens to a claim once it leaves the practice. A claim is followed as it moves along the claims submission and health processing networks. Understanding this flow will enable physicians to better address the delay, denial and reduced payment tactics used by health plan payers.
17. Losing revenue through inappropriate health plan adjustments
The AMA developed the educational resource Is your practice losing revenue through inappropriate health plan adjustments? (PDF, 176KB) to alert physician practices of the need to carefully review health plan explanations of benefits in order to pinpoint and address underpayments based on inappropriate adjustments by the health plan.
18. Performing an internal billing audit
The AMA, with cooperation from the American Academy of Neurology, developed the educational resource How to Perform a Physician Practice Internal Billing Audit (PDF, 58KB) to help physician practices understand both the need for an internal billing audit and how to perform an internal billing audit to yield improved claims management processes, cash flow, and compliance with applicable laws and regulations.
19. Preparing for health plan retrospective audits
The AMA, with cooperation from the American Academy of Neurology, created the educational resource How to Prepare for a Health Plan Retrospective Audit (PDF, 582KB) to educate physicians and their office staff about the recoupment efforts of health plans through the retrospective audit process. Physician practices can use this resource to guide them through the retrospective audit process from the initial notification from the health plan to contesting the audit’s findings.
20. Getting paid what you deserve for out-of-network treatment
The AMA has developed the educational resource Out-of-Network Payment Challenges for the Physician Practice (PDF, 151KB) to provide physicians and their office staff resources to understand the health plan payer’s obligation for payment to out-of-network providers. The resource explains some of the payment challenges that arise when a physician who is considered out-of-network requests payment from a patient and/or health plan.
21. Stopping unfair payer practices
The AMA has developed the brochure What to do about Unfair Payer Practices (PDF, 95KB) to educate physicians on alternatives, or additional complaint mechanisms, available to them beyond those presented through a health plan’s internal complaint submission process. This brochure will guide physicians and their office staff through the process of filing a complaint against health plans with state insurance regulatory agencies.
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22. Combating inappropriate health plan claim denials
The AMA developed the educational resource How to Appeal Inappropriate Health Plan Claim Denials (PDF, 131KB) to educate physicians and their office staff about appealing erroneous payment reductions and denials. This resource also includes tips to assist physicians in identifying and appealing inappropriate health plan claim denials.
23. Improving practice efficiencies with electronic claims submissions
The AMA, in collaboration with the Connecticut State Medical Society, developed the educational resource The benefits of electronic claims submission - improve practice efficiencies (PDF, 126KB) to help physicians and their practice staff understand the electronic claim submission process and the many benefits that may be realized by submitting claims electronically to health plan payers. The resource discusses the reduction of claim submission costs and errors, and offers tips on getting started with electronic submission.
24. Electronic Funds Transfer Agreements
The AMA developed the educational resource Frequently asked questions regarding electronic funds transfer agreements (PDF, 29KB) in response to physician concerns regarding electronic funds transfer agreements.
- Tiered and narrow physician networks (PDF, 206KB)
This booklet provides definitions of tiered and narrow physician networks, explains how they work, quantifies some problems that may be associated with their use, and concludes with a table that models some tiered and narrow networks. - How physician incentives are used to impact the medical practice – This product is only available by hard copy. To obtain this product, please contact Susan Close at (312) 464-4835.
- Medicare Advantage: What it means for you and your patients. (PDF, 621KB) Physicians can use this booklet to begin to understand the many changes as a result of Medicare Advantage and to help their patients make informed decisions about the health care they receive. This booklet describes:
- Medicare Advantage Health Plan Options
- Regional PPOs and Regional Prescription Drug Plans
- Medicare Advantage Physician Participation and Contracting
- Medicare Part D – Prescription Drug Program
- Medicare Advantage Special Needs Plans
Special Needs Plans are coordinated care plans that serve special needs individuals which include the institutionalized, dual-eligible, and chronically ill. This brochure (PDF, 109KB) provides information on the background of these specialized plans, defines each segment of this unique population, and gives information on how insurers offering these plans are funded. - Health Plan Funding and Physician Reimbursement
Medicare Advantage plans receive a fixed per-member-per-month payment from CMS, who in turn pay physicians on a contract or fee-for-service basis. This brochure (PDF, 104KB) provides detail on how insurer payment is determined and how physicians are reimbursed in coordinated care and private fee-for-service plans.
Content provided by: Private Sector Advocacy