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Important Issues in Fee Collection and Insurance Billing Laurie Conaty. LCSW. LCAS. PAConsultation.Clinical [email protected]
Disclaimer• It is important to consult with a tax advisor, an attorney or
another professional about any contracts and/or tax decisions one might make.
• The suggestions contained herein are those based on the presenters experience and should not be construed as legal and/or tax advice.
• The presenter cannot guarantee that you will have the same experience in contract negotiation by following these guidelines as she /her practice experienced.
• One is always responsible for practicing within the scope of one’s ethical and legal practice. Nothing contained herein absolves one of that sole responsibility.
What is Insurance?
• Insurance is a financial support for accessing MEDICALLY NECESSARY CARE.
• The key language is Medical Necessity.• Personal growth and/or insight is typically not language that
will convince a third party payer of “medical necessity.” Advice-stay away from that language when negotiating providership on a panel or working with a UM representative.
• So, what is indicated medical necessity?— documented signs and symptoms that indicate medical necessity for care. And, a treatment plan that is oriented towards goals (embedded in best practice) that reflect the elimination or the management of noted signs and symptoms.
Points to Know in Negotiating with an Insurance Company• Know your State licensing statutes-as an LCSW, you have
“parity” with other MH professionals. If an insurance company pays for services provided by a MD-psychiatrist or a PhD/PsyD, then they must pay for services provided by a LCSW.
• If an insurance company is based out of NC, but “sells” their product (insurance) to “covered lives” in NC, they must comply with insurance regulations in NC—i.e., LCSW’s have parity.
• http://www.ncga.state.nc.us/enactedlegislation/statutes/pdf/bychapter/chapter_90b.pdf
• Know the market-often insurances will say a network is closed. They will have a list of providers in network. Check their list of in-network providers-if the providers are no longer practicing, be prepared to advise contact person of that.
Points to Know in Negotiating with an Insurance Company• Have plenty of time to be on the phone.• Always be respectful and also assertive.• Unless or until you hear a point that makes sense and is
logical, do not accept no for an answer.• If there is a point that is logical and makes sense, you will have
to decide if you want to make the requisite changes/additions to your practice in order to earn the business of the insurance company.
How to Set Yourself Apart• Measure your key outcomes-return appointments kept after initial
appointment and average length of treatment episode in major dx categories. Be willing and assertive in articulating outcomes.
• Knowledge AND USE of evidence-based practices-be able to be articulate about EBP’s for various dx and your ability to implement these (coordination of care with a MD (psychiatrist) for mood disorders along with CBT, for example. DBT for borderline personality disorder and other challenging diagnoses.
• Get trained and certified (if applicable) in EBP’s.• Develop a “one stop shopping” practice or be able to demonstrate
a very tightly organized network of providers. Having a psychiatrist for med management is important. Both of these “sell” to insurers who are interested in comprehensive and well coordinated care.
Key Considerations in Billing• Be sure that you have a policies and procedures agreement
(contract) with patients that describes how you handle your billing and what they are responsible for and the time frames.
• Submit claims right the first time—every time a claim is ‘touched’ it is lost income (whether in house or out of house)
• Immediately “work” denials (day received or the next day)-the person working denials must : 1. know what they are talking about; 2. be assertive and 3. keep the responsibility for working the wrongly denied service on the payer (the insurance company.) If it was accurately denied, then the person must ask how to submit the rebilling in the most expeditious way; 4. ALWAYS KEEP TRACK OF WHO YOU TALKED TO AT WHAT NUMBER ON WHAT DAY AND AT WHAT TIME; 5. Keep a ‘tickler’ file to follow back up if claim is not paid within 2-4 week window, depending on insurer.
ICD 10 – Are you Ready? October 1 is ‘roll out’ date• Like most insurance companies, BCBSNC will be ready to process
the ICD-10 codes on October 1, 2015 and will not accept ICD-10 codes before the October 1, 2015 implementation date. There will be no grace period or dual use period for ICD-9 codes after October 1, 2015. The following rules will be used:
• Professional claims: • If the dates of service are greater than September 30, 2015, use ICD-
10If the dates of service are less than October 1, 2015, use ICD-9,If the dates of service span October 1, 2015, split the claim so that one claim covers the time before October 1, 2015 and the other claim covers the time from October 1, 2015 and later.
•
More on ICD-10• Remember: the date of service determines which codes to use.
Use ICD-9 codes for dates of service prior to October 1st, and ICD-10 codes for sessions October 1st and after. Don’t put pre-October dates of service on the same claim form as sessions October 1st and after.
• Many plans won’t pay if you only list a “phase of life issue “or relationship issue (what was a V-code in the ICD-9, now a Z-code in the ICD-10).
• Avoid “Unspecified” diagnoses, as plans may not reimburse for them — plans are looking for increasing specificity in diagnosis. When you have the choice between an “Unspecified” and “Other Specified” diagnosis, choose the latter, and document in the chart what criteria were not met for you to use another diagnoses of this category.
Considerations
In House or Out of House-pros and cons with each• In house billing can serve several roles in the practice-both
billing and administrative, to include fee collections.• Purchase billing software or using each insurance companies
website?• In House-Provider typically has more control and depending
on fiscal considerations, the billing person can fulfill other roles
