Establishing Your Insurance Contracts
One of the first questions a patient will ask a provider is, “Do you accept my insurance?” While this is a loaded question, you want to be able to tell the patient, “Yes, we accept your insurance and we are an in network provider.” Out of network is a scary phrase for patients and providers who are unfamiliar with insurance, therefore, we have placed an emphasis on a provider to become a participating/in network provider with many insurance networks. However, before you jump into and accept any and all contracts once an insurance panel opens, it is important that you take the proper steps to ensure you are setting your practice up for long term success.
1. Do your homework – review local insurances that are common in your area and research their policies, reimbursements rates, etc. Is the insurance a flat rate payor? Do they have a cap on modalities/units per day? What is their fee schedule and what percentage of their fee schedule are they offering to you in your contract?
2. Do you have a niche? Does your clinic have specialty equipment or do you have a certification that allows you to specialize in a certain area or treatment style? Any of these specialty services can set your practice aside from other providers and can give you an edge while negotiating a contract with a payor.
3. Are you in a densely populated area or are you the only provider in the region to offer a specific service to the insured in your area? This is also a great negotiating point when trying to get into an insurance panel or negotiating a rate with a payor.
4. Know your worth and do not settle! Advocate for your practice, our profession and the importance of the specialty services you can provide.
5. Show them the money – literally. Utilize outcomes, quality measures, net promoter scores, etc to prove your value to the insurances’ beneficiaries.
Credentialing and Recredentialing Your Locations and Providers
Once your insurance contracting is executed, the next step is to set up credentialing for each location of your practice and for each of your individual providers. While this process may seem daunting, remaining organized and in constant contact with each insurance company is key. Typically, the contracting and credentialing department at each payor can guide you on what documentation is needed in order to attach your locations and individuals to your established group contracts. This takes time and you should take into consideration that once a credentialing application is submitted to the insurance, it can take between 30 – 120 days before you receive a response. Some key points as you navigate through this process are:
1. Ensure accurate effective dates for your practice and your providers:
Be sure to inquire with the payer about backdating of effective dates. Some insurances may backdate to the date that the application was received. If you are expecting an approval, you can be riskier with these insurances and start to see patients for this payor once the application has been confirmed received.
Do not bill a new payer contract until you have confirmed the effective date. If you bill claims with dates of service prior to receiving your fully executed contract, you will surely receive denials that won’t uphold appeals. Knowing the effective date of a contract or a provider’s participation date is a critical piece of the credentialing process. This will ensure your claims are paid and avoid unnecessary denials.
2. Ensure proper time frame for credentialing:
Familiarize yourself with the time frames it takes to receive approval for credentialing and re-credentialing. These time frames vary widely payor to payor.
Ask for confirmation of receipt when submitting an application. Follow up every two days until confirmation is received.
After you’ve received confirmation of receipt, follow up every two weeks until approval is received.
Keep a spreadsheet to organize progress, follow up intervals, and responses.
Set reminders to ensure no follow ups are missed!
Always get a reference number for every single call you make to an insurance company!
3. Ensure billing and credentialing departments are communicating:
Your billing and credentialing departments should have a solid process in place for communicating credentialing status’ and how that directly affects the submission of claims.
It is essential that your credentialing department shares all crucial information with your billing department, including: pending, approved, and terminated credentialing status’; claims that need to be held and when those claims are okay to be submitted; and contract intricacies to ensure that the EMR and claims reflect the contract details.
Establishing Your Fee Schedule Within Your EMR
This is an arbitrary number that gives you an idea of what your reimbursement per visit will be for each date of service rendered. It is usually marked up from the Medicare fee schedule. You want to mark it up so that you are able to capture all different payor and payor sources allowed amounts. Generally, PIP/Auto insurances will pay more than the Medicare fee schedule. But if you bill these claims at the Medicare fee schedule, then that is what you will be reimbursed.
If you need to change your fee schedule for any reason it is good to take note that your payment percentage will also change. Your payment percentage is a historical calculation of your paid claims divided by the amount that you charged for those claims. If you track paid percentage and disallowance on certain codes, once you change your fee schedule, that percentage will also change. This is something that is always okay to do, however, you will not be able to compare it to your historical data. Ideally, it is crucial to set this up properly from the start and then monitor your paid percentage closely to look at trends in your reimbursement. This is a key metric to monitor the health of your practice.
Setting Up Your Payors and Payor Rules Within Your Documentation System
Make sure you are establishing each payor with the correct payor guidelines.
AMA vs CMS
The main difference under AMA guidelines is that the AMA does not calculate the total time or cumulative time of a treatment session. They consider each unit and each unit must be at least 8 minutes in order to bill for it. This is why some people call the AMA guidelines the “Rule of 8’s.”
Per CMS, in order to bill one unit of a timed CPT code, you must perform that associated modality for at least 8 minutes. Medicare calculates the total time spent in a treatment session and divides by 15 to figure out how many units are rendered on a given service date. If eight or more minutes are left over, you can bill that time as an additional unit. If 7 or less minutes are left over, you must drop those minutes and not bill for them. Simply put, Medicare takes total time and uses the chart below to determine how many units were rendered on a particular treatment session.
8-22 minutes : 1 unit
23-37 minutes : 2 units
38-52 minutes : 3 units
53-67 minutes : 4 units
68-82 minutes : 5 units
83 minutes+ : 6 units
2. Each payor also has a specific set of rules around modifiers, evaluations, authorizations, etc. Make sure these items are set up properly from the start to avoid denials, patient balances and messes on the back end!
The Front End Basics
Insurance verification and authorizations play an essential role in avoiding denials and patient ineligibility for services. They are also a key component in your customer service.
While it is the patients’ responsibility to know their benefits, we are all aware patients often do not even know what a deductible is - let alone how much they have remaining on it. If you do not present this information at the time of service, you could be dealing with an angry patient down the line after he or she receives a statement.
What Does the Insurance Verification and Authorization Process Entail?
There are several things that should be obtained when an insurance verification is completed. These include: payable benefits, co-pay amounts, co-insurance amounts, deductible amounts, effective date of plan, additional coverage details, whether authorization (or prior authorization) is required, confirmation of claims address, the patient's yearly maximum, etc. While some insurances allow you to check benefits online and they can be completed fairly quickly, other insurances require up to an hour (!!) spent on the phone to obtain benefits. Ensuring this process is done correctly on the front end will save your team a significant amount of time and resources on the back end to avoid denials as well as make your practice more money to get claims paid the first time around.
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As we continue to navigate through everchanging reimbursement models, new edit changes and constant fluctuations of authorization requirements, it is important to continue to maintain, manage and measure the health of your practice to ensure proper steps were taken and are continuing to be completed. Below are some key metrics to look at on a quarterly basis to take a quick glance if the above is being completed properly.
Denial/First Pass Payment Rates
How many denials are you receiving and how many claims are paid on the first submission? Many factors go into these metrics including accuracy of patient intake and registration information, correctness of insurance verification and authorization information, and how claims are being submitted per payor guidelines. A very efficient practice will have a denial rate under 5% and a first pass claim rate higher than 95%.
Percentage of Receivables over 120 Days
How quickly are you collecting the money you are owed? You should be aiming for less than 10% in the 120+ aging bucket. There are always going to be issues with specific claims but a healthy practice has about 75% of their AR in under 60-days outstanding.
Payer Mix/Expected Revenue per Payer per Visit
Who are your top 5-10 payers? What are they paying you per visit? Your overall cash flow is very dependent on your payor mix and what each payor is paying you per visit or per unit on average. This is an important metric every practice should monitor closely. Maybe it is time to try to renegotiate contracts, to consider going out-of-network with some insurances or maybe it’s time to use your marketing dollars more strategically.
These are only a few of the metrics you should be reviewing on a monthly basis, however, they will give you the big picture overview of how your practice is doing.