Out of Network Coverage for Drug & Alcohol Rehab

We have gotten many phone calls from people who have had a family member that was in an inpatient drug and alcohol rehab facility that didn’t accept their insurance. Of course when the family member was admitted it was a crisis situation, and there was little choice as to what options were available. In many cases it is actually life or death. They certainly can’t be driving around looking for a participating facility.

The problem is that these out of network facilities require payment for the services up front. Since they do not participate with the insurance, they need to make sure they will be paid. The only real way for them to ensure payment is to get it in advance. Again, due to the situation, the family has no choice so they borrow, or charge, or whatever they need to do at the time.

A lot of times their insurance will have out of network benefits available and the patient (or family member with the insurance) can get reimbursed. The problem is that the facility doesn’t submit the claims. They usually provide the patient with a ‘walk out’ statement, or some other form that shows the charges.

The insurance companies usually require that the charges be submitted on a UB04 form, which is the universal claim form for facility billing. It isn’t that they don’t want to pay, but the information that they require is not on the walk out statement that the facility has provided to the patient. The facilities don’t know how to complete these UB04 forms, and they’ve already been paid. Many times they truly want to help the patient get reimbursed but they simply don’t know how.

We have found a way to help out both the patients and their families, and the facilities. Solutions Medical Billing Inc has teamed up with Xena health to provider a service of taking all of the necessary information from the facility and putting it on to a UB04 form to submit to the insurance carrier. Now patients have a way to get the proper forms filled out and submitted to their insurance carrier so that reimbursement can be made promptly. For more information on how this service works, visit www.facilitybilling.com

Misconceptions of Increasing Accounts Receivable

Misconception # 1

Alice and I had the honor of speaking at the Mid York monthly billing meeting in Syracuse last week. Our topic was “12 Misconceptions of Increasing Accounts Receivable”. We decided the topic was a good one and have decided to share the presentation in it’s entirety over the next couple of newsletters.

Since Alice and I are in a lot of medical offices we see a lot of different situations. Most providers are looking for ways to increase their accounts receivables. Whether they are just looking to make more money, or if they plan on expanding, or if they are not bringing in enough money to cover the expenses of the office, they all are looking to bring in more money. The problem is most of them have the wrong ideas on how to accomplish that.

The very first misconception we spoke on is one of my personal favorites. Many doctors will say to us “If I want more money, I need to see more patients.” What I say to them is that if they want more money, they need to make sure they are getting paid for all the patients they are already seeing and all the services that they are performing.

Many doctors are not even aware of how many patients they are seeing, how much is being billed out, how much is coming in, and how much is being written off. Are the write offs due to contractual adjustments? What percent of claims are being denied? Is their staff taking care of the claim denials, or just writing them off. A survey was done by the Medical Association of Billers in 2004 and they found that only 45% of respondents had ever appealed a denied claim. That means that 55% of respondents do not take care of denied claims. That can be a huge money loss for the provider.

Is your staff running and working regular aging reports? This is another area that much money can be lost. Are copays being collected? Is patient billing being done? If your claims are being submitted electronically, are the electronic reports being downloaded and handled.

As you can see there are many ways that money can be lost in a medical office. If a doctor wants to increase his/her accounts receivable they should first look into if they are collecting all they should be on the patients that they are currently seeing. If they are not collecting all that they should, bringing more patients into the system will just make it worse.

Coinsurance Uncovered

Now we’ve covered copays and deductibles, that leaves coinsurance. Coinsurance is a term used by the insurance carriers to refer to the amount that the patient is required to pay for a medical claim.

If a patient has an indemnity insurance plan then they would not have a set copay or a set amount that they are responsible for. The amount the patient will owe will be determined when the claim is processed.

For example, if the patient has an 80/20 indemnity plan, then the insurance carrier will pay 80% of the allowed amount and the patient is responsible for the remaining 20%. So if a provider bills $120 for an office visit and the insurance company allows $100, then the insurance would pay the provider $80 and the patient would owe $20.

The problem this presents for the provider is that the patient cannot be charged for their portion at the time of the visit. Since the amount the patient owes cannot be known until the claim is paid, the provider must wait until the insurance carrier processes the claim before they can bill the patient.

Many times with indemnity plans the patient also has a deductible that must be met first. After the deductible is met then the insurance carrier will begin to make their payments. Again, even when you know the patient has a deductible you can’t charge them up front. You must wait to find out what the insurance carrier is going to allow for your services. You can only charge the patient the allowed amount, not the billed amount.

Coinsurances can vary depending on the plan. They are not a set amount like 80/20. They can be 70/30, 90/10, etc. You should call when the patient comes in initially to find out what type of insurance plan they have. Just advise the patient that they will be billed for their responsibility as soon as their insurance carrier makes payment.

This is a good example of why it’s important to make sure your claims are being submitted and processed timely. If you are billing a patient for their portion 2 weeks after their visit instead of 6 months, you are more likely to get paid.

Medicare Applications – Which Form Is Used To Become A Medicare Provider

Medicare requires that you complete specific forms put out by CMS when applying to become a Medicare provider. Sounds easy enough but have you seen the list of forms that they have? How are you suppose to know the correct form to complete and once you figure that out, what fields on the form do you need to fill out?

If you are a solo provider, can you bill under a tax ID number (EIN number) or do you have to use your social security number? Is it necessary if you use a tax ID number to apply for a group Medicare number? And why would you need to reassign benefits to yourself?

Well it’s really not as complicated as it seems. If you are a solo provider and you are using your social security number for your tax ID number then you need to complete an 855I, 588 EFT, and a CMS 460. The CMS 460 is the participating provider agreement. You only need to complete this if you choose to be a participating Medicare provider. The 588 EFT is the Electronic Funds Transfer form. Medicare requires that you accept EFT and they will transfer your payments directly into your bank account. The 855I is the individual provider application.

If you are a solo provider who is going to bill under a tax ID number but you are a sole proprietor you also would need to complete the 855I, 588 EFT and the CMS 460.

When applying for a group, you will need to complete an 855B, an 855I for each provider in the group, an 855R for each provider in the group, a 588 EFT, and a CMS 460. The 855B is the group application and the 855R is to reassign the benefits of each provider to the group. If you are a solo provider but you have formed a corporation, you need to apply for a group application for the corporation.

The forms are available on the internet. You must complete the appropriate forms and send them in to the Medicare carrier for your area. It is crucial that you complete the forms correctly to avoid delays. If your application is not completed completely or correctly the carrier will request the additional or corrected information from you. If you do not respond or respond timely your application may be closed.

Deductibles in Depth

Last month we explained in detail all about copays. Now we are going to cover deductibles in depth. A deductible is a set amount of medical expenses a patient must pay to become eligible for insurance benefits under an insurance program.

What does that mean exactly? It means that before an insurance company begins to make payments for a patient, the patient must meet their deductible. How does a patient meet their deductible? Many people get very confused over how this is actually accomplished.

In order for a patient to meet their deductible claims must be submitted and processed by the patient’s insurance carrier. When the claims are processed, the amount that is applied to the deductible is the allowed amount for the services being billed. So for example, if the claim is for an office visit, 99213 for $80, and the insurance allows $55 for a 99213, then $55 will be applied to the patients deductible, not $80.

Deductibles can vary anywhere from $50 to $5000. If it is a private plan purchased by the patient the deductible depends on the plan the patient purchases. Plans with lower deductibles cost more than plans with higher deductibles. If the insurance plan is thru an employer then the deductible is determined by the employer and how much they pay for the insurance plan.

Some people mistakenly think that the patient has to pay them the amount of the deductible and then the claims that are submitted will be paid by the insurance carrier. They don’t realize that the insurance carrier must actually receive claims for the patient in order to apply them to the deductible for the deductible to be met.

The best thing to do is to call the insurance carrier before the patient is seen and inquire as to the amount of the patient’s deductible and if any of it has been satisfied yet. You must also remember, you don’t know which other providers the patient may have seen and whether or not a claim was submitted for those services.

Usually you will need to submit the claim and wait for the insurance carrier to process it and apply it to the patient’s deductible before you can bill the patient. Many providers like to charge the patient up front when they know that the patient has a deductible that hasn’t been met. This isn’t always the best thing to do since there are many factors that can affect the amount the patient owes.

For example, if you call when the patient comes in and are told they have a $200 deductible and it hasn’t been met yet, and the patient is being seen for an office visit and a urinalysis. The office visit is $80 and the urinalysis is $15 for a total of $95. You make the patient pay the $95 since the deductible is not met. However, you submit the claim and the insurance company allows $60 for the office visit and $12 for the urinalysis. That is only $72. If you participate with that insurance carrier then you can only charge the patient $72 or you are breaking your contract. You’ve already collected $95 so now the patient has overpaid.

Another problem with collecting up front is that a claim by another provider may beat your claim in. If you call when the patient comes in and they tell you the deductible is not met, you charge the patient up front. Then your billing person is out sick for a couple days, or gets busy doing other jobs and the claim doesn’t get submitted for a couple weeks after the patient’s visit. (Trust me, this happens a lot.) In the meantime the patient goes to Urgent Care where they submit their claims electronically the same day the patient is seen and their claim beats yours. Now the patient’s deductible is suddenly met, and the insurance carrier makes payment on your claim. Again, another overpayment.

If a patient has a deductible then usually once the deductible is met the insurance carrier will pay a percentage of the allowed amount and the patient will have a coinsurance. (We’ll talk about coinsurances next month.) Many plans today are getting away from the deductible/coninsurance and moving more towards the HMO/PPO plans that have set copays. However, it is still crucial that you understand exactly how the whole deductible thing works. There are still several plans out there with deductibles, including traditional Medicare plans.

Medicare Changes Carriers

On September 1, 2008 many of the Medicare contracts across the country changed carriers. In some areas it went very smooth and most providers didn’t even notice, but in some areas it wasn’t quite as smooth of a transition. Our local Medicare Carrier, Upstate Medicare, was changed, but I have to say it was a fairly smooth transition. Although I think a lot of that is due to the fact that the new carrier NGS, is subcontracting many of the processes to the old carrier, HealthNow.

I happened to be submitting a Medicare application for a provider in Northern California right around September 1^st though and the carrier for Northern California Medicare also changed. The problem that I had there is that no one seemed to know who the new carrier was, including CMS. After doing many web searches I was finally able to find a new phone number, but when ever I dialed it was busy. Several days of busy signals made me realize that I wasn’t going to get thru, so I went back to searching the web. Finally the new carrier was able to get the website updated to include the new address for provider enrollment.

In any case, if you have been suddenly having trouble with your Medicare carrier, it may just be that your carrier is no longer who you thought it was. By now most of them have worked the bugs out, but if not give it a few more days. Unfortunately dealing with these types of changes is all part of the game.

The Truth About Copays

Many people get very confused by all the different ways that insurance companies process claims and how they calculate what the patient owes. It is crucial that the providers have someone in their office or a good billing service that knows how to read the eobs and that they are billing the patients correctly.

Many plans today have a straight copay that is due at the time of service. Sometimes the copay is different for the patient’s PCP than it is for a specialist, but it is still a straight copay. For example, if a patient goes to their regular doctor for an asthma check or a physical, they pay $15 but if they go to a podiatrist or a chiropractor the copay is $25. In either case the patient is usually accustomed to and willing to pay the copay at the time of their visit.

A lot of the insurance companies print the patient’s copay information right on their ID card. It will say PCP copay $15 Specialist copay $25, or whatever. Some do not print the copays on the card. Usually the patient knows what it is, but some patients do not realize that they have a higher copay for specialists. It is a good idea to call the insurance carrier to verify a copay if it is a new patient. Especially if you are billing for a specialist.

Most offices will ask for the copay when the patient checks in which is a good idea. There may not be a good opportunity to get it on the way out. For example, if the patient doesn’t need to be seen again they may not even need to stop back at the desk. Or if they don’t feel well and they spend an hour and a half in the office, they probably just want to get out of there. It’s just a real good idea to collect the copay when the patient checks in. It eliminates the need to bill a patient later if they get out without paying the copay.

Sometimes patients do not want to pay the copay. Copays are due at the time of service according to most of the contracts that insurance companies require the provider signs to be in their network. It is not the providers who set that rule. If the patient truly just doesn’t have the money, then it’s ok to cut them a break and let them bring it in at another time or bill them. I went to urgent care once with a urinary tract infection. I was in agony and when I got there I realized I had forgotten my purse. They were nice enough to see me even though I couldn’t pay my copay and I didn’t even have my insurance card. I stopped by later that day with the card and the copay.

Since it is better to collect the copay up front, you should definitely try to get it then. But if you are going to allow the patient to be seen without paying the copay, you should let the patient know that you are doing them a favor. If you have pre-printed envelops with the office address on them, it’s a good idea to give one to the patient for them to send the copay in. They are more likely to stick it in the mail if they have a pre-printed envelope.

Many providers don’t realize that they are actually breaking their contract with the insurance carrier if they DON’T charge the patient the copay. If a provider is regularly not charging for copays and an insurance carrier finds out, they can terminate the provider’s contract. This is actually a great tool to use for patients who try to get out of paying the copay. The provider can tell them that if he gets caught not charging the copay he can be thrown out of the patient’s plan.

If you have a patient with a hardship case and the provider is going to forgive a copay, or forgive all copays for a period of time then the patient’s file should be well documented. For example - a patient’s husband was in a bad automobile accident and is out of work for a period of time and the provider decides to forgive her copays while the husband is out of work. The patient’s file should clearly indicate exactly why the copays aren’t being collected. Give details, such as “Pt’s husband in auto acc on 8/3/08 and out of work indefinitely. Only collecting 50% pay. Have 5 children.” Or whatever the case is.

Of course there are always the patients that don’t have to pay their copays. The patient’s wife’s cousin, the son of the doctor’s college roommate, etc. Most insurance companies will allow a couple of cases without getting too upset, but they definitely frown at skipping the copays on too many patients. Providers need to be particular at who they give breaks to.

Bottom line, copays actually work out best for a provider since they know up front what the patient’s responsibility is going to be and can collect it prior to seeing the patient. It is always easier to get paid up front than to have to bill the patient. Make sure the person checking the patient in is consistent about collecting the copays.