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.

Medical Payer : Who Is It and Who Has the Money? Part 2

Medical Payer : Who Is It and Who Has the Money? Part 2

Most patients have a commercial healthcare insurance plan that pays a portion of the cost should they become ill or require medical attention.

Commercial plans account for the bulk of a practitioner’s reimbursements, but an extensive array of government operated insurance plans are available that offer an added source of revenue.

Nitin Chhoda wraps up his two-part series on medical payers with a look at government-funded healthcare insurance.

medicalThe federal government sponsors an array of healthcare insurance medical programs for military personnel and their dependents, the elderly and disabled, low-income individuals, and employees that are injured at work.

Originating at the federal level, some programs are administered by individual states or through regional contractors.

Medicare
The largest government operated insurance plan is Medicare, serving the disabled and those 65 or older. It’s essential for practitioner to verify a patient’s Medicare coverage.  Medicare is confusing to medical clients and many mistakenly believe they’re enrolled for services when they’re not.

Medicare prefers to pay providers via electronic fund transfer and most claims are paid without problem when submitted correctly. Use electronic medical record technology whenever possible to facilitate the payment process. Medicare is comprised of four components.
•    Part A – Pays for home healthcare, hospice, in-patient hospital stays and skilled nursing facilities.
•    Part B – is optional and pays for medically necessary services.
•    Part C – is a replacement plan for employer-based policies that allows individuals to enroll in a private healthcare plan if they desire.
•    Part D – covers prescriptions.

Medicaid
For low-income individuals and some Medicare recipients, Medicaid assists by paying all or a portion of their medical bills. The program follows federal regulations, but may be administered by private healthcare companies. Practitioners may find it difficult to verify a patient’s eligibility status and Medicaid maintains a fee schedule that’s not negotiable.

Tricare
Funded by the Department of Defense, Tricare is used by active military personnel and their dependents. Coverage is separated into three parts to address the different healthcare needs of the individual.

The medical plan pays a set amount and practitioners are expected to accept that amount as full payment, without billing patients for the difference.

•    Tricare Standard – is used by active, reserve and retired military personnel, and eligible family members.
•    Tricare Prime – serves the same individuals as Tricare Standard, but requires members to seek treatment from network providers only.
•    Tricare for Life – is a supplement for former Tricare members who are eligible for Medicare.

CHAMPUS VA
The Civilian Health and Medical Program of the Uniformed Services provide coverage for VA patients who don’t qualify for Tricare, along with spouses and children of veterans disabled or killed in the line of duty. CHAMPUS works much like an HMO, and requires referrals and prior authorizations.

Workers’ Compensation
Employees who have been injured or disabled on the job, or acquired an occupation-related disease, are eligible for Workers’ Compensation. Providers must enroll and be assigned a Department of Labor number. Medical services must be medically necessary and receive prior authorization. Clinicians of healthcare practice management must ensure all procedures are reported and have a verified diagnosis code from Workers’ Compensation.

Medical records must be included with the reimbursement claim and practitioners must provide regular follow ups. Even then, clinicians aren’t guaranteed payment, which is distributed according to a pre-determined fee schedule.

medical payersPayments are made via electronic fund transfer. Workers’ Comp claims are submitted to one of three divisions – Federal Employees’ Compensation, Division of Coal Mine Workers’ Compensation and Division of Energy Employees.

Government-funded healthcare plans offer practitioners additional source of revenues, but claims must adhere to the strict standards set forth for each program. Filing a medical claim can be a time consuming process, but can be facilitated through the use of an EMR to ensure accuracy and timely reimbursements.

Why Medical Necessity is Necessary

Why Medical Necessity is Necessary

Medical professionals must prove that that a particular service or treatment was necessary before a patient’s healthcare insurance provider will pay for it.

Medical necessity trumps other criteria in the adjudication process and Nitin Chhoda provides new insights into why proving medical necessity is necessary, particularly in the current healthcare climate.

medical necessityMedical Necessity
Medical necessity refers to steps taken to evaluate, diagnose and treat disease, illness and injury.

Procedures, and the reason for performing them, form the heart of the medical necessity clause.

Insurance companies won’t reimburse for anything that doesn’t fit the definition of medical necessity.

Preventative measures may be medically necessary, but that doesn’t mean they will be deemed necessary by an insurance provider. In an era of abbreviated healthcare insurance policies, some forms of preventative care may not be covered at all.

It’s All About the Money
Receiving a reimbursement denial interrupts revenue and requires valuable time to rectify or appeal. It’s an especially frustrating experience for practitioners, who often feel that they’re being second guessed by individuals with no practical knowledge of the patient in question.

For insurance companies, it’s all about the money. If medical professionals want to be paid, they must provide documentation to support their actions.

Insurance companies base their payment decisions on a set of parameters that utilize a generally accepted set of procedures. To ensure services remain within the medically necessary rule, practitioners should focus on performing an exam that’s relative to the client’s complaint and document elements of their history as it applies to the visit. If documentation falls short of the intended billing code, bill at a lower code.

ICD and CPT codes
Documentation of medical necessity is supported by ICD-9 and CPT codes. During the adjudication process, insurance companies refer to the ICD and CPT codes clinicians provide. They’re the nuts and bolts of a reimbursement claim. Inclusion of coding that supports findings and actions at the time of the patient’s visit are essential for facilitating the payment process.

Practitioners should be aware that certain codes in medical billing convey a wealth of information in clusters. Many of these are used frequently and in conjunction with specific problems that occur together.

medical necessitiesIt’s important to learn which of those codes are used together most often and ensure multiple patient issues are reflected in the coding choices.

Clinicians often see the medical necessity clause as a tool to withhold or ration services to patients and payments to providers.

Insurance companies view it as a way to save money, ensure they’re not paying for superfluous services, and not padding the pocketbook of practitioners.

The medical necessity clause serves as a check and balance system. To get paid, it’s up to clinicians to provide proper ICD and CPT codes that offer documented proof that the services they provided meet the definition of medical necessity.

The Life of a Claim: How You Get Paid

The Life of a Claim: How You Get Paid

The clock starts ticking on the life of an insurance claim the moment a patient makes an appointment and doesn’t end until the practitioner is paid. To better understand the life cycle of an insurance claim, Nitin Chhoda offers a first-hand look at the process.

claimFirst Contact
When clients contact a practice, it sets in motion a process in which it can take up to three months for the clinician to be paid.

Before patient arrives at the office, staff should already have obtained and verified the individual’s healthcare insurance information to ensure the policy is in force, hasn’t lapsed and who is covered, along with any limitations or restrictions.

Insurance benefits can be tricky to navigate. Clinicians must ascertain exactly what’s covered under the patient’s claim insurance, their deductible and co-pay when they make an appointment. It will impact the client’s available treatment options. Some individuals have coverage under more than one insurance provider. Both policies must undergo the same rigorous verification.

Patients will also be required to sign consent forms allowing the practitioner to bill the insurance company and be paid directly, release information for billing, and for the client to pay any amount not covered by insurance claim. A copy of the client’s identification and insurance card is required, along with a complete health and medical history.

Enter the EMR
All the client’s information must be entered in the practice’s EMR for medical billing. Incorrect or incomplete information will delay reimbursements to the clinic, as will failure to obtain an authorization for procedures. Insurance providers will deny a payment if the correct forms aren’t used, information is incomplete and for other breaches of the company’s particular set of rules.

To document the client’s visit, clinicians will create an encounter form that provides pertinent information about the patient’s complaint, exam, diagnosis and procedures performed. Any secondary problems that are observed must be documented and all the information entered into the EMR. Each diagnosis and procedure code must match or the claim will be denied.

Calculating Fees
Clinicians can now enter the cost of the visit utilizing their schedule of fees. Each procedure and all materials must be calculated into the final cost, from the use of the exam room to bandages. It’s also time for the patient to determine how they’ll pay for any portion of the cost for which they’re responsible.

That can take the form of cash, check, debit or credit cards, or a payment plan. Collect at least a portion of the payment before the client leaves the office.

Submitting the Claim
A reimbursement claim must be prepared and sent to the client’s insurance carrier, complete with documentation of the patient’s financial and clinical information from their visit. Each claim should be double checked to ensure that codes and patient information match, and that there are no omissions, or the claim will be delayed.

The claim will examined in extensive detail by the insurance company to ensure the client is covered, any restrictions and limitations were adhered to, accurate coding was included and information is complete. insurance claim

If a problem arises, the clinician will be asked for additional information or to resubmit the claim.

Practitioners can appeal the decision, collect any unpaid amount from the client or write off remaining costs.

It can take a typical claim up to three months to be reimbursed, even without any difficulties. Using an EMR ensures HIPAA compliance, protects against loss, decreases processing time and accelerates the entire process for quicker deposits and better cash flow.

Payer : Who Is It and Who Has the Money? Part 1

Payer : Who Is It and Who Has the Money? Part 1

Medical professionals collect reimbursement payments from a variety of sources. Known as payers, they encompass commercial insurance companies, third-party administrators and government-funded programs.

In part 1 of this revealing article, Nitin Chhoda identifies the major commercial payers and third-party administrators, and what clinicians need to know to obtain reimbursements.

payerA wealth of commercial insurance plans payer exists to help individuals pay for medical expenses. That includes preferred provider, point of service, health maintenance, and discount plans.

To ensure that services are paid for, practitioners must verify the client’s coverage each time they visit the office and ascertain any limitations as it will have a direct bearing on treatment options.

When contracting with a payer, it’s important for clinicians to know if the insurance company is the entity that actually sets the amount that medical professionals are reimbursed. Some participate in a payer network that determines how much practitioners are reimbursed for their services. Some networks pay better than others and clinicians should exercise due diligence in researching payers.

Commercial insurers
The most common form of insurance practitioners will encounter is the commercial policy, typically offered through the patient’s or spouse’s employer. This type of coverage will fall under one of the following:

•    PPO – A preferred provider network is a group of healthcare professionals and facilities that have agreed to provide services at reduced rates.
•    HMO – Health maintenance organizations rely on a network of healthcare providers, but clients are assigned a primary care physician and care must be accessed through that physician.
•    POS – Point of service coverage is a hybrid blend of a PPO and HMO payer. Patients who visit an HMO medical provider are covered under HMO benefits. If they see a PPO provider, they receive coverage through the PPO.

•    EPO – An exclusive payer or provider organization plan requires patients to select a primary care physician and obtain a referral before seeing a specialist.
•    High deductible plans – These offer patients low monthly premiums and deductibles that can begin at $4,000 or more.
•    Discount plans – These plans require patients to pay a monthly fee to obtain access to participating providers. They’re not true healthcare insurance plans.
•    COBRA – Coverage under a Consolidated Omnibus Budget Reconciliation Act plan is a payer that is dependent upon patients making their monthly payments on time. If a payment is late, claims will be rejected or the coverage cancelled.

A COBRA plan is interim coverage when an employee loses or leaves their job.

Third-party administrators
A third party administrator (TPA) or payer is the middleman of healthcare. TPAs are operated as an independent network, or price claims by accessing other networks.

They handle claims for employers who insure their own employees rather than participating in a commercial group program. medical payer

Reimbursement problems can arise for clinicians if the TPA prices the claim incorrectly or the claim isn’t paid according to the individual TPA agreement.

Before contracting with a payer, it’s essential for practitioners to determine which entity sets the cost of services and what those payments will be to the practice.

Different networks and commercial insurers for medical billing have their own set of rates and reimbursement requirements that must be met for clinicians to be paid and practitioners must conduct sufficient research to ensure they’ll be reimbursed appropriately.

Medical Billing — Its Role and What it Means to Your Office Structure

Medical Billing — Its Role and What it Means to Your Office Structure

A structured medical practice is essential to ensure that reimbursement claims are submitted in a timely manner.

Missing, lost, misplaced or improperly filed patient records creates unnecessary medical billing delays and interrupts the flow of funds into the practice.

billingOrganization is the key to a well-run practice that treats as many patients as possible and generates a steady stream of reimbursement claims for medical billing and coding specialists to process.

In the absence of clear cut rules, direction and procedures, waste and chaos results. Distracted billers can make costly mistakes.

Filing practices
Maintaining accurate and easy to access patient records is essential if a biller is to do his/her job. The information contained within the patient’s record is the basis upon which reimbursement claims are filed.

Incomplete, inaccurate or illegible records cause delays in medical billing and can easily result in a payment denial or rejection. The information needed to obtain payment must be maintained in a manner that allows billers to quickly access the information they need to submit claims.

Each to his own task
In smaller practices, staff members may be required to wear a variety of hats, including the clinic’s medical billing and coding specialist. While it’s possible for a clinic’s healthcare staff to multi-task by answering phones, looking up records, scheduling appointments and communicating with other healthcare facilities and pharmacies, it’s not conducive to medical billing practices.

Each team member should have set responsibilities and clear cut job descriptions to avoid wasted effort. That’s not to say that personnel shouldn’t be cross trained to handle other duties should the need arise. Clinicians need to plan for such contingencies and ensure staff has a clear understanding of what to do in specific circumstances.

Set office hours
Setting regular office hours allows patients to know exactly when the clinician is available and keeps practitioners from being pulled in too many directions at once. Scheduling appointments to see clients allows providers to best utilize their time and provides medical billing specialists with a steady stream of claims to submit throughout the day.

Some healthcare professionals prefer the walk-in method of seeing clients with no appointment necessary.

It eliminates the problems of cancellations and no-shows, but there’s no way to ascertain how many patients may or may not arrive.billing and documentation

Clinicians could find their medical billing specialists have few reimbursements to submit.

A well-structured office is one that operates efficiently and where every detail of a patient’s visit is carefully documented and filed for retrieval by the practice’s medical billing specialist.

Careful organization and an eye for detail ensures that billers have the information needed to process reimbursement claims to maintain a steady cash flow into the clinic.