LEARNING WHAT IT TAKES TO BILL MANAGED CARE INSURANCES

Transcription

1 home health LEARNING WHAT IT TAKES TO BILL MANAGED CARE INSURANCES Lynn Labarta, CEO, Imark Billing 1

2 home health LYNN LABARTA CEO, Imark Billing Founder of Imark Billing with over 15 years experience in billing for home health and hospice agencies nationwide. Imark Billing: home health & hospice billing company 2

3 WHAT WE WILL COVER TODAY Understanding the insurance/managed care space Detailed information on how to manage billing processes How to manage collections from insurance/managed care payers Dealing with claim denials and managing through them to avoid losses to revenue and profitability 3

4 INTRODUCTION Are you missing out on additional revenue sources because you are afraid of commercial insurance providers? Just by understanding several key components of the commercial insurance/ managed care process you can significantly increase your revenue. 4

5 LEARNING OBJECTIVES Understand the different types of commercial/managed care payers Identify the Eligibility and authorization process Know the billing process Review the collections and follow up process Understand Denials and How to avoid them 5

6 PAYOR DIVERSIFICATION Payer diversification is a must in today s environment The fact is that Medicare is squeezing our reimbursement and increasing regulatory requirements and compliance Consider alternative sources of revenue Commercial payers Managed Care Medicaid HMOs Workers Comp insurances 6

7 CONTRACTING WITH INSURANCE COMPANIES Contracting MYTH Do not always have to be in-network or contracted with an insurance company to be able to accept the patient You need to know your market if you are going to contract with insurance companies. Priority number one is to find out which insurance companies operate in your area. Large companies like UHC, AETNA, HUMANA, BCBS, etc. Smaller, local companies in your area 7

8 CONTRACTING WITH INSURANCE COMPANIES Many commercial payers will require accreditation to be a contracted provider. You will need to contact them to find out what they require. Applying to an insurance company is not automatic guarantee that they will accept your application Many times, admission to insurance companies is determined by specialty, regional need and demand. If you offer special services such as IV therapy, wound care specialist, pediatrics or something that may set you apart from other home health, be sure to let them know! 8

9 CONTRACTING WITH INSURANCE COMPANIES GO to insurance company s website, go to provider section, enrollment Call insurance company and ask for enrollment department It is not a difficult process it just takes time 9

10 ACCEPTING INSURANCE Staff education is a must for success It is important to understand that Medicare HMOs and Commercial insurances are different and will have different requirements Read the contracts--- they will indicate the specific requirements the insurance is requesting 10

11 TYPES OF INSURANCE Payers can be Complex Each insurance company can have hundreds of plans so know what plan the patient has Best practice is to obtain a copy of the patient s insurance card helps identify the type of plan 11

12 TYPES OF INSURERS Medicare HMO also known as Medicare advantage or Medicare replacement plans Typically follows Medicare guidelines 12

13 TYPES OF INSURERS Commercial Insurance PPO Not related to Medicare 13

14 TYPES OF INSURERS Medicare HMO Must do OASIS and transmit OASIS to CMS Require HIPPS codes and treatment auth codes Billed episodically like Medicare Raps and Finals required May or may not need F2F or PECOS 14

15 TYPES OF INSURERS Commercial insurance Do not require OASIS No HIPPS codes or treatment authorization required Pre-visit payers Typically billed weekly or monthly 15

16 TYPES OF INSURERS - SUMMARY Knowing the type of insurance plan the patient has will help you understand what process you are going to follow in the office Medicare billing and commercial/hmo insurance billing are completely different 16

17 ELIGIBILITY PROCESS Must find out if patient is eligible before admitting (call insurance company) Availity.com (free service) Not properly performing the eligibility could lead to non-covered services that will not be reimbursable 17

18 ELIGIBILITY PROCESS VERY BASIC, CRITICAL QUESTION: Ask if the patient is eligible for Home Health services 18

19 ELIGIBILITY PROCESS OUT-OF-NETWORK Are there out of Network Provider coverage? W9 form required 19

20 ELIGIBILITY PROCESS AUTHORIZATIONS Are Authorizations required? Must be obtained before you admit the patients Most commercial insurance plans require authorization prior to admitting patient Medicare HMO varies 20

21 ELIGIBILITY PROCESS AUTHORIZATIONS Your authorizations usually cover a certain number of visits over a set period of time. If your patient requires more services an additional request and authorization is required in writing and an approval is too kept on file and in software. Track your authorizations in software 21

22 ELIGIBILITY PROCESS DEDUCTIBLES Does the patient have a deductible? Has that deductible been met? Collect deductible up front Out of network providers may have larger deductible 22

23 ELIGIBILITY PROCESS CO-PAYS AND CO-INSURANCE Does the patient have any co-pays? Collect upon each visit Coinsurance-Does the patient have to pay % of the allowed amount 23

24 ELIGIBILITY In order to confirm insurance eligibility, must have following info: Patient s name and date of birth Name of the primary insured Social security number of primary insured Insurance carrier and phone number ID number and Group number 24

25 ELIGIBILITY PROCESS SUMMARY Once you ve got the insurance information in-hand, you should contact the insurance company to verify the following pieces of information: 1. Patient is indeed covered by the insurance and for Home Care services 2. Insurance coverage effective dates 3. In-network or out-of-network coverage 4. Service(s) you are seeing the patient for are covered - do they need preauthorization? 5. Amount of co-pay for services, if any 6. Deductible amount: has the deductible been met for the year? 7. If possible, during patient visit obtain copy of insurance card and collect any applicable co-pay/deductibles 25

26 BILLING PROCESS PAPER OR ELECTRONIC Avoid paper billing whenever possible Electronic billing is best 26

27 BILLING PROCESS VISIT CODES, UNITS AND BILL RATES Schedule visit with the appropriate visit codes required by each insurance company Medicare HMOs G -codes Commercial insurance sometimes use G-codes but can also use S codes or T codes or just Revenue Codes Check that your bill rates and units are set up correctly as per contract 27

28 BILLING PROCESS AUDIT CLAIMS Before you submit claim review the claim to ensure that it follows the requirements 28

29 PAYER SETUP PROCESS Payers must be setup in software Add payer rules in the software so you can subsequently bill these claims correctly 29

30 BILLING PROCESS - EDI Possibly may need to fill out EDI application for some payer (electronic data interchange) Insurance companies portals Direct submissions using a clearinghouse (such as Availity) 30

31 BILLING PROCESS TIMELY FILING Know when is it too late to submit claim days - timely filing deadlines Commercial insurances bill weekly or monthly Medicare HMOs- episodically or monthly 31

32 BILLING PROCESS FOLLOW UP Without a timely follow up process you will have reimbursement issues and cash flow problems. They key is having billers that are properly training and familiar with each step of every insurance company s billing process. Most insurance companies use stall tactics to delay payment. Don t let them get away giving you inaccurate information. Don t be afraid to challenge the insurance representatives. If you are not happy with the response you get from the insurance representative try to reach their supervisor or call again to get another rep on the phone. 32

33 BILLING PROCESS FOLLOW UP Follow up with submitted claims within 2 weeks (some payers 30 days) Can be done by phone or by logging into portals Claims payment time frames are days depending on payer 33

34 BILLING PROCESS FOLLOW UP Correspondencecorrections maybe required EOB- (Explanation of Benefits) payment info and denial info Checks sent by mail Sign up for EFT (electronic funds transfer) 34

35 BILLING PROCESS FOLLOW UP When you receive payment on a claim-- check that it s paid according to contract Check for underpayments 35

36 DENIAL MANAGEMENT Most denials are related to billing errors You may be able to correct this denial with a simple phone call, refilling the claim electronically or submit an appeal letter File your corrected claim as soon as possible (about 7 days from denial) to avoid timely filling deadlines 36

37 DENIAL MANAGEMENT Implement a process for tracking and monitoring claims. If possible, assign insurance follow-up staff members to particular payers, so they become familiar with those plans. Don't automatically refile claims that are denied, Follow up with a phone call first. Prioritize follow-up efforts. The goal is to bring in more revenue, so first work the high-dollar claims and those that can be corrected easily. Denied claims serve as a training opportunity. 37

38 COMMON DENIALS AND HOW TO HANDLE THEM Claim not on file Incorrect patient identifier info No Authorizations Coverage terminated None Covered services Missing or invalid CPT/ HCPCS codes Timely filling 38

39 BILLING REPORT Accounts receivable aging- a report that shows the claims billed and for how many days they are outstanding. This report allows you to identify potential issues from a high-level view We recommend that any claims outstanding for over 60 days need to be worked 39

40 Q & A Time! Imark Billing Lynn Labarta ext 101 labarta@imarkbilling.com Get Paid 3x Faster with IMARK Maximize Profits. Minimize Errors 40