The Realities of Billing Insurance in the Private Practice Setting

Transcription

1 The Realities of Billing Insurance in the Private Practice Setting The Good, The Bad, and The Ugly By Ginger Bailey, RDN, CD

2 Conflict of Interest No conflict of interest are known

3 Objectives Give RDs more background about the process to go about billing insurance to help them decide if it is something they want to do or not Provide a general overview about compensation and benefits that can be received from billing insurance Provide a realistic understanding of the downside to billing insurance companies and the challenges that are involved Provide resources for RDs choosing to move forward with billing health insurance Answer questions RDs have about billing in private practice

4 Bio Ginger Bailey was born and raised in Salt Lake City, Utah. She graduated from Utah State University with honors from the Coordinate Dietetics Program. She worked as a Clinical Dietitian and Diabetes Educator at LDS Hospital for 8 years before deciding to start her own practice. She is married and has three children: 8 year old twin boys, and a 3 year old son. In her spare time she enjoys sports, music, reading, and is close to earning her black belt in Aikido.

5 Is billing health insurance right for me? Do you have a way to get credentialed with insurance companies? Learn to do it yourself Find a company to do it for you Do you have the software to create and submit claims? Do you want to spend the extra time to submit claims and follow-up when they get denied? Are you willing to learn how to code and create claims or are you willing to pay a company to do it for you? Do you have a way to invoice clients for an amount due later? Are you willing to wait for payment?

6 The Good Reasonable compensation Increased access to care for patients It lends legitimacy to the profession of dietetics Free marketing! (my personal fav)

7 The Bad Getting a practice set up to bill insurance is complicated and a bit costly Increased admin time Following up on failed/rejected claims is time consuming and aggravating Delay in payment or sometimes no payment Fine print in the credentialing contracts can cause a lot of headaches if you don t understand them

8 The Ugly Insurance can demand money back after paying you. Patients will still get mad because they didn t understand their benefits Not all treatment codes that dietitians are allowed to bill are payable Claims get complicated when a patient has dual coverage

9 The Ugly (continued) Insurance will often deny valid claims repeatedly so you will give up and they don t have to pay (for reals) Collecting money from people later gets complicated People move They avoid paying They get mad they owe money Collections agencies are often unhelpful and incur more expense Lose patients when insurance doesn t pay for their visits Medicare no longer covers treatment for obesity (will only pay for diabetes and chronic kidney disease with an MD referral). Some insurances only allow 1 or 2 diagnosis

10 How to get set up to bill insurance Step 1: Credentialing Who will do this? You will need to gather info Business name EIN or TIN NPI (you will need to get one if you don t have it) Individual and group NPI Business License Number Registration Number Educational history Professional Liability Insurance References (personal and professional) Information for billing company if outsourcing

11 Step 1: Credentialing Medicare is most complicated Each insurance has their own process Recommend creating a CAQH profile because many insurances use that as part of credentialing Most insurances have a provider relations department you can contact to find out how to go about getting credentialed Ask if their panel is open for dietitians before doing any more work

12 Credentialing (cont.) Can take weeks to months for applications to be approved Once application approved, they will send a contract to sign Make sure to read the contract. It should include their reimbursement rates, and the required timeframe that claims have to be submitted in. After getting credentialed look for a copy of their billing guide and become familiar with it. Each insurance has their own.

13 Step 2: Submitting claims In Utah it is required that you submit claims through a clearinghouse. The middle men than send the claims on to the insurance company. They review the claim first to make sure that is generally correct so the insurance company does not immediately deny the claim Some you have to pay for, some are free Don t work will all insurance companies. They will have a list of the ones they do. Can be submitted on paper, but most do it electronically Software to submit claims Recommend getting a software that will generate electronic claims to submit if you do not outsource the billing MNT Assistant

14 Step 2: Submitting Claims Coding Claims Do you have or need a physician s referral? Required for Medicare and some insurances Kinds of codes to be familiar with Diagnosis codes (ICD 10) 60,000 codes Treatment codes (CPT codes) Only certain codes can be billed by RDs. Each insurance allows and disallows certain codes. Commonly billed codes: 97802, 97803

15 Submitting Claims Preventative care policy (in accordance with the Affordable Care Act). Many patients are able to get covered by this policy. Insurance pays 100% of the claim without patient needing to meet their deductible. Important to understand the stipulations (a.k.a. loopholes) with each policy: Only cover 3 visits per year Require documentation to be submitted to prove medical need Require that more than one diagnosis code are used with certain conditions Only apply if the patient also sees a physician at the same visit

16 Submitting claims Benefits checks: Perform a benefits check prior to submitting claims Some insurances allow you to do this online through the provider portals It can be confusing Not all insurances have benefits section specific to RDs Sometimes classified as out-patient, or it s own category

17 Step 3: Claim Adjudication Adjudication process takes about days Each claim will have adjudication codes with abbreviations which are listed on the EOB CO: contractual obligation NP: No payment PR: Patient responsibility Oncce accepted, the amount billed will be adjusted to the contract pricing which is different for each insurance and can vary depending on codes used If a claim is denied, you may have to submit a corrected claim or an appeal. Each insurance has a process for how to go about this that you have to learn.

18 Step 4: Receiving Payment Can have checks/eobs mailed to you or done electronically (EFT) EFT is usually faster Review EOB (explanation of benefits) statement If denied, may require a call to insurance to find out why May need to invoice if there is a patient responsibility May need to submit claim to secondary insurance. Not all insurances automatically forward on the claim to secondary insurance company. Some EOBs are sent through the clearinghouse Most insurances reimburse between $ /hour visit

19 Resources Payment/FeeScheduleGenInfo/index.html Certification/MedicareProviderSupEnroll/index.html

20 Summary Billing insurance can help decrease time and cost spent on marketing, however is very complicated and significantly increases admin time. If you outsource the billing you still have to provide the company with the information they need to submit the claims and they will often only submit one invoice to the patient. Admin time is at least double to triple the amount for insurance vs. self-pay even once you understand the process. If deciding to bill insurance, accept that there will be some patients you never receive payment for Learning to bill insurance is very difficult if you don t have someone to teach you It can be a viable way to have a more steady client base

21 Questions? Anyone feel like this now?