Healthcare from the Government – Your Biggest Payer, Part 2

Healthcare from the Government – Your Biggest Payer, Part 2

Medicare is the biggest government payer practitioners will deal with, but it’s by no means the only one. Government-operated health insurance encompasses many other programs and in this second of a two-part series, Nitin Chhoda addresses other government-sponsored insurance plans.

healthcareHealthcare insurance programs operated by the government provide coverage for veterans, low-income adults and injured workers.

Managed by the federal government, some programs are administered at the state level.

All have very specific regulations and can require pre-authorizations, referrals, and proof of medical necessity before they approve reimbursements.

Medicaid

Next to Medicare, Medicaid is one of the best known healthcare insurance programs in the U.S. Designed to provide the poor and low-income individuals with basic health services, it’s administered at the local level. Each state has considerable leeway in the manner in which it administers the program, determines individual eligibility, and what services are provided.

Funding cuts to Medicaid at the federal level has resulted in many states limiting coverage to the most basic levels for adults. The program also provides limited  healthcare coverage for those who require nursing home care. Children in the program receive dental and vision services, along with healthcare. Medicaid patients are entitled to surgical procedures, inpatient hospital treatment, and prenatal care.

It’s extremely difficult to verify a patient’s Medicaid eligibility, what portion of the bill the client may be responsible for, and what services are covered until the actual reimbursement claim is submitted. Medicaid maintains a stringent fee schedule, regardless of actual costs.

Tricare

Funded by the U.S. Department of Defense, Tricare is the healthcare plan that serves active military personnel and their dependents. Tricare encompasses three levels of care – Standard, Prime and Life. Tricare Standard is for active duty, retired and reserve retirees, and their family members. It operates similar to a PPO. Recipients are required to pay a deductible and copay, but can see any civilian healthcare provider.

Tricare Prime resembles an HMO and serves the same segment of the military as the Standard. Patients have more restrictions and must only utilize network providers. Tricare for Life is a supplement plan for former Tricare members that are eligible for Medicare. The plan pays according to a fee schedule similar to Medicare.

CHAMPUS VA

The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) serves VA patients and those not eligible for Tricare, along with spouses and dependents of military personnel who were disabled in the line of duty. Surviving spouses and dependents of veterans killed due to military-related injuries are also eligible.

CHAMPUS healthcare plans are usually secondary payers. When it’s the primary payer, the plan functions much like an HMO. It’s imperative that coverage is verified prior to the client’s visit to ascertain if a referral or pre-authorization is required before treatment is provided.

Workers’ Compensation

Administered by the U.S. Department of Labor, Workers’ Compensation is available for workers injured while on the job or who develop an occupation-related disease. Practitioners must enroll in the healthcare program and obtain a DOL number.

Workers’ Comp claims always require pre-authorization, but that doesn’t guarantee payment for services.

Before treating a client, verify pertinent information about the disease or injury with the employer. A diagnosis code must be approved by the Workers’ Comp carrier and the medical provider must prove medical necessity.

healthcare programClinicians should obtain a pre-authorization for every procedure. Workers’ Compensation claims are paid according to a healthcare pre-determined fee schedule, and funds deposited through electronic fund transfer.

Patients covered by government-operated healthcare programs can add significantly to the revenues of any practice, but clinicians should exercise caution especially with their medical billing and make sure to verify every aspect of the client’s coverage prior to treatment.

Government healthcare plans have numerous rules, regulations and filing requirements and if they’re not followed to the letter, reimbursements won’t be forthcoming.

The Ins and Outs of Your Clearinghouse

The Ins and Outs of Your Clearinghouse

Clearinghouse represents the first step on a reimbursement claim’s journey toward money in a clinician’s pocket, but a lot can happen once it’s transmitted from the practitioner’s office.

In this revealing article, Nitin Chhoda provides an inside look at factors that can affect a claim and the ultimate reimbursement.

clearinghouseBefore And After

A clearinghouse is an essential element of the entire medical or physical therapy billing cycle. They ensure that each claim is routed to the appropriate insurance company for payment.

They perform other useful functions before a patient arrives at the office and afterward. Billers can utilize their services to ascertain a client’s insurance eligibility and coverage prior to treatment. They can also issue a statement of services to patients.

Cleaning the Claim

The first step for a claim after its arrival at the clearinghouse is a thorough scrubbing for errors and inconsistencies. Some mistakes can be quickly corrected online, allowing the claim to continue on its journey. These are typically clerical errors and while they may seem minor, they contribute significantly to the wait time for the claim to be paid.

Other problems aren’t so easily rectified and the entire claim will be returned to the clinician’s office to be corrected and resubmitted. These types of problems can arise when the clearinghouse doesn’t recognize the payer. Many smaller insurance companies don’t accept electronic payments and the claim will be returned, necessitating submission of a paper reimbursement request.

Matching Identification

Clearinghouse is responsible for matching payer identification numbers with the right claim, a process that tells the organization where to direct the reimbursement request. The practice’s billing and coding specialist must include the correct payer ID number on the claim or it will be returned to the medical provider, further delaying reimbursement.

Reports and Records

Medical clearinghouse maintains a record of each claim that goes through the facility’s system and generates a status report.

The record can be accessed by the practice and used to monitor the location of the claim, where it was sent and when. Sometimes a claim may seem to disappear. Billers can check their batch report against those generated by the clearinghouse to discover what happened to it.

clearinghouse - in and out

Clearinghouse provides clinicians with a single location to manage all their reimbursement claims and to do so electronically for speedier payment.

Multiple claims can be submitted at the same time and clearinghouse reports allow clinics to track and monitor the status of any claim 24/7.

Practitioners that contract with clearinghouse have the advantage of fewer rejected and denied claims and quicker reimbursements.

Medicare: The Government – Your Biggest Payer, Part 1

Medicare: The Government – Your Biggest Payer, Part 1

Clinicians will contract with many commercial insurance providers during their careers, but the heavy hitters of reimbursements are government-backed insurance plans.

In this informative two-part series, Nitin Chhoda examines programs operated by the federal government and what practitioners should know about them.

MedicareGovernment-operated healthcare programs encompass Medicare, Medicaid, Workers’ Compensation, CHAMPUS and Tricare.

Of all the government-run insurance plans, Medicare is the largest and is comprised of four types of coverage, Part A, B, C and D.

Participation is mandatory for some portions and voluntary for others, leading to confusion for patients.

Congress dictates how Medicare claims are paid. Reimbursement requests must be submitted within a specified time frame and the agency prefers to pay providers via electronic fund transfer.

It’s critical for practitioners to verify which Medicare elements a client participates in before services are rendered.

Medicare Part A

The first part of Medicare coverage pays for inpatient care in hospitals, skilled nursing facilities, home healthcare and hospice, but an overnight stay in a hospital is no guarantee of payment. Clients must meet specific requirements for Medicare to pay for inpatient services.

Medicare Part B

The B portion of Medicare coverage is designed to pay for services, treatments and procedures that are medically necessary. Included are services by physicians, home health services, durable medical equipment and outpatient visits. Some preventative measures are covered, including vaccines.

Part B is optional, but those who don’t enroll according to government guidelines are penalized. Patients often believe they’re automatically enrolled when they retire and are dismayed to discover they have no coverage. Recipients also have an annual deductible and pay a 20 percent copay for services.

Medicare Part C

Part C, also known as Medicare Advantage, is an insurance replacement plan offered by private companies that have been Medicare approved. Part C is favored by individuals who prefer private insurance coverage. Depending on the provider, plans can require beneficiaries to pay out-of-pocket expenses, obtain referrals, and only see network providers.

Replacement plans can be used to cover Part A and B services, and some plans include medication and vision coverage. To avoid medical billing reimbursement difficulties and appeals, always verify the client’s coverage, restrictions and limitations prior to treatment, along with the plan’s fee schedule to determine if it differs from Medicare standards.

Medicare Part D

The Medicare prescription drug plan is Part D. While Part D coverage doesn’t typically cause a problem for medical professionals, a large number of Part D recipients mistakenly believe they’ve enrolled in a Medicare supplement policy. Practitioners may find they’re spending a significant amount of time explaining the difference to their patients.

Medicare Supplement Plans

Patients can enroll in a Medicare supplement program, also known as Medigap plans, to cover the costs that Medicare doesn’t pay. It provides a source of secondary coverage, but doesn’t include any non-approved Medicare expenses. Always verify secondary coverage prior to any patient encounter.

Medicare coverageMore than 50 million people age 65 or older and younger individuals with disabilities have some type of Medicare coverage.

It represents a large population of patients upon which practitioners can draw that are covered by a reliable payer.

Incentive payments may also be available for clinicians practicing in geographic areas with a demonstrated shortage of medical professionals.

Reimbursement Using EMR System — The Secret to a Low-Delay Claims

Reimbursement Using EMR System — The Secret to a Low-Delay Claims

As insurance companies scrutinize reimbursement submissions more closely, clinicians are enduring longer turnaround times to collect money on claims.

The simple installation of an integrated EMR can transform those extended waits for funds into a low-delay reimbursement system and Nitin Chhoda explains it here, in this article.

reimbursementEMRs enable faster reimbursements and can detect claims with potential problems before they’re submitted, virtually eliminating denials.

The majority of denials and contestations can be traced to simple human errors in data entry and by preventable problems that can be avoided by verifying a client’s insurance coverage before services are rendered.

An integrated electronic medical record submits claims electronically to arrive almost instantaneously at the intended destination and can detect an extensive array of errors and notify practitioners prior to submission.

Human Data Entry Mistakes an EMR Can Help Avoid

Mismatched, incorrect procedure codes and improper patient information that doesn’t reflect the information for the client’s complaint is a common cause of denials. An example would be listing a procedure for a male when the client is female.

Each insurance provider has its own set of rules for reimbursement submissions. That includes specific claim forms. An infraction results in an automatic denial until the correct forms are submitted.

Health insurance providers are requesting prior authorization for an increasing number of treatments and procedures. If the clinic fails to obtain authorization, the insurance company can refuse to pay clinicians anything.

It happens infrequently, but a patient may need to see their healthcare professional twice in the same day to receive the same or similar treatments. Practitioners encounter difficulties when submitting these types of claims. Insurance companies view this as a duplicate reimbursement request and will reject it automatically.

It would seem like common sense, but clinicians who don’t file reimbursement claims in a timely manner will forfeit payment. Practitioners have one year to file their claim and such oversights can cost clinics thousands of dollars.

Check the Facts Before Treatment Begins

In a time of high unemployment and loss of benefits, it’s essential for practices to verify insurance coverage and client information before the patient ever reaches the clinic. An EMR provides the means to accomplish these and other tasks with alacrity, reimbursement claims included.

Insurance coverage that has lapsed, been terminated, wasn’t in force when the patient received services, and clients not eligible for coverage represent a major reimbursement problem for practitioners. All of that information can be ascertained easily prior to the patient’s appointment.

Many healthcare insurance providers are offering basic or minimal services and few patients understand their coverage or limitations. It’s imperative that clinicians determine the type of treatments covered under each insurance plan.

What constitutes a reasonable fee for practitioners and insurance companies varies widely. Each insurer has its own guidelines on the amount that can be reimbursed for specific treatments and reimbursement claims that exceed which will be rejected for unreasonable fees.

reimbursement claimsClinicians and insurers also differ on procedures. Ordering a CT scan instead of a less expensive x-ray can result in a determination of not medically necessary by the insurance company and loss of income for the practitioner.

An EMR represents the best solution for a low-delay reimbursement system. It has the tools to identify an extensive array of human errors that will delay or prevent claim payments.

An integrated EMR is the key to verifying patient information and insurance coverage to ensure practitioners receive the reimbursement to which they’re entitled.

Claim Appeals 101

Claim Appeals 101

Reimbursement claims can be denied at any time and for any number of reasons. Most problems can be remedied easily, but when talking fails to facilitate a desirable outcome it may be necessary to file an appeal. In this revealing article, Nitin Chhoda addresses the basics of filing an appeal.

clearinghouseMost appeals in the billing process, physical therapy billing included. will involve commercial insurance companies.

How a clinician approaches an appeal has a huge impact on how quickly and smoothly the process is concluded.

Unfortunately, the onus is on the practitioner to prove why a claim wasn’t processed properly for payment. That requires knowledge of the payer and the terms of the contract that was signed with the insurance provider.

Provider Relations

Many contracts include a prompt pay clause that can cost the payer fees and interest on late payments if they didn’t file or process the claim according to the terms of the contract. The first point of contact when filing an appeal will usually be provider relations to ascertain if the claim was received and how it was processed.

A phone call can be all that’s needed to quickly remedy the situation. Some payers provide online reconsideration forms that can be submitted, while others require a formal written appeal. It’s critical to maintain complete documentation of all verbal and written communication associated with the appeals process.

Provider Representative

If the claim wasn’t processed due to the contract loading incorrectly in the payer’s software system, the next step is to speak with the provider representative. This individual is charged with ensuring the contract between the medical provider and payer is correct and loaded in the claims processing software system.

Expect to be vetted and answer specific questions about the claim. The provider representative may be able to locate the problem and solve it.

Representatives also have the power to send the claim back to the payer for reprocessing.

Written Appeals

If a phone call fails to resolve the issue, a written appeal must be submitted. It should include all the pertinent information about the claim and clearly state the expected outcome for settlement. Explain why the actions are being sought and further steps that will be taken, such as referring the matter to the practice’s attorney.

Exercise Control

Appealing a claim rejection is time consuming and frustrating. It’s critical to exercise control and professionalism at all times. claim submission

The appeals process relies on facts for resolution and it’s important to clearly state the problem and the payment expected. Refer to specific clauses in the contract to prove points.

A denied or rejected claim delays payment and appealing the decision can require considerable time and effort.

The process is sometimes necessary to collect the fees to which clinicians are entitled and it’s important to keep a cool head throughout the process.

Most disputes with commercial payers can be solved if practitioners approach the situation armed with the facts and the terms of the payer contract.

Insurance: The Rules, Regs and Who Makes the Decisions

Insurance: The Rules, Regs and Who Makes the Decisions

The rules governing healthcare insurance procedures are as varied as the companies that offer policies. Payers may choose to follow the same regulations as government backed insurance plans, while others have developed their own unique set of parameters.

It’s essential for billers to be familiar with them all and electronic medical record expert (EMR), Nitin Chhoda, has released new data on who makes the rules that govern reimbursements.

insuranceWho Controls The Purse Strings?
When it comes to clinicians being reimbursed for the services they render, practitioners should never forget that insurance companies are firmly in control of the entire process.

Each payer has its own set of policies, procedures, manuals and submission requirements. The payer establishes the rules and regulations that medical billers and coders must follow to ensure clinicians are reimbursed.

Practitioners typically contract with commercial insurance companies to reimburse them when one of their covered clients seeks medical attention. Most individuals have insurance through their employer and the payer underwrites the plan, complete with financial caps, treatment limitations and the need for prior authorization and referrals.

Networking Opportunities
Insurance companies control access to providers through the employment of networks. The insurance company maintains a network of medical providers with which it has a contract. The arrangement ensures a steady stream of patients for practitioners.

In return, the clinician agrees to receive specific reimbursements for services to limit outlays by the insurance company.

Contract Specifics
Contracts define time limits for submitting claims, how long the insurance company has to pay the claim, and the type of plans included in the agreement. Fee schedules, procedures that require preauthorization or referrals, and the appeals process are clearly spelled out.

Other payers choose to adhere to the fee schedule set forth by Medicare, modify the fees to pay 110 to 125 percent of what Medicare reimburses, or even pay less. Even though the medical provider may receive less than the Medicare fee, insurance company executives know that patients covered under their plans represent a substantial client base.

The Path to Payment
Most claims result in prompt payment, but the potential always exists for the payer to repudiate a reimbursement. Practitioners must use caution when negotiating contracts with payers, be cognizant of the terms, and long-term implications. Appeals can be filed when necessary.

Much of the reimbursement process relies upon the medical billing and coding specialist entering the correct codes, and ensuring documentation complies with the payer’s submission specifications.

insurance guidelines

Payer-practitioner contracts should be loaded in the practice’s EMR software to facilitate clean claims.

Insurance companies call all the shots when it comes to reimbursements. Clinicians must be vigilant when negotiating contracts with payers to ensure they’re receiving the best return for their services.

A great many payers exist, each with its own set of rules, regulations and requirements, but with a good billing and coding department, participating in a network of insurance providers can be a good investment for the practice.