Rill Unique Blog

BHO - What is that?

12/14/2011 15:34:00

If you are a mental health professional looking to work with health insurance carriers then you should familiarize yourself with BHOs, or Behavorial Health Organizations. The primary purpose of most health insurance policies is to handle those ailments caused by physical problems and not mental or psychologically based problems. Therefore, when someone is needing assistance with psychologically based problems, there is a wealth of information and details that must be kept and administered too. Because of the differentiation, Behavorial Health Organizations have evolved. They are responsible for assisting insurance carriers with those needs related specifically to mental health issues, or psychologically based concerns. With the complexity of working with mental health disorders, there are numerous BHOs that are apart of the complete system. Many of your major insurance carriers such as Aetna and Cigna, have their own separate BHO that deals only with mental health benefits. Yet that still does not mean that the mental health benefits for Cigna patients are all exclusive to Cigna Behavorial Health only (CBH), they may also contract with other BHOs too. Another robust example is that of Medicare and Medicaid. Within the state of Colorado, Medicaid sub-contracts with five (5) different BHOs to cover all of the counties with the state. You will find the same type of dispersement for Medicare and Medicaid in other states too. While the 'system' seems complex and overwhelming, once you began to learn the different BHOs and their own specific rules, claims processing becomes a lot easier. An important detail to remember is although you may be listed as an in-network provider with a major health insurance carrier, that DOES NOT mean you are in-network provider with the BHO. You will have to go through similar credentialing steps to join the BHO network in addition to the health insurance carrier network. Although, you may be a in-network provider with the BHO without being an in-network provider with the health insurance carrier to see insurance patients. You also want to keep in mind that many substance abuse patients insurance claims are paid by the insurance carriers and not the BHO since their condition is consider physically based and not just psychological although treatment may including counseling. If you wondered what a BHOs track record may be, see if they are listed with NCQA, the National Committee for Quality Assurance at http://reportcard.ncqa.org/mbho/. This is also a great site to check out the standing on health insurance carriers too.

Version 5010 - Are You Ready?

11/22/2011 14:58:00

Version 5010, are you ready? If you work in the healthcare industry you should be VERY AWARE of the major changes occurring with insurance claims processing. Due to inaccuracies in reporting information gathered from claims and incorrect payments made due to code choices, the healthcare industry will be migrating to the use of ICD-10 codes. This means that diagnosis codes will go through a major overhaul, expanding from five (5) alpha numeric places to seven (7) alpha numeric places. To enable our systems to recognize the new codes, especially the code lengths, and process claims electronically accordingly, the first step is to implement Version 5010. Currently all claims processed electronically to any type of carrier uses an electronically formatting of the codes inputted known as Version 4010 (aka v. 4010). Effective January 1, 2012, all claims are to be transmitted with Version 5010 (aka v. 5010) in preparation of the use of the ICD-10 codes in 2013. Due to the change, carriers, software vendors and clearinghouses have been undergoing tedious amounts of testing to ensure that there are no service interruptions on the January 1, 2012 deadline. Therefore claims using ICD-9 codes will began to be transmitted with the new v. 5010 layout. While this has been the talk in the industry for well over a year, there are still numerous of providers or billing agencies that are not prepared for the January 1st deadline. Based on the feedback from these entities, CMS and others have chosen to have a discretionary enforcement date of March 31, 2012. What does this mean? They may chose to not enforce fines for failure to begin transmitting claims in v. 5010 until March 31, 2012. Although this does not guarantee that will be the case as the official deadline is January 1, 2012. Another side note about the new v. 5010 is the 'billing provider address'. Before you were allowed to use a PO Box in this field, which will no longer be permissible with v. 5010. If you input a PO Box in this field, the claim will be denied/rejected. Any PO Boxes must now be listed in the 'pay-to' field. If you are processing claims electronically, which for most carriers these days is mandatory, you should have already completed testing or are at the end of testing. Other then these two options, you will not be ready and therefore risk claims being processed efficiently which will affect your cash flow. So I ask once again, Version 5010, are you ready??? Rill Unique Enterprises is ready.

Credentialing Tid Bits

11/05/2011 11:16:00

Have you considered joining insurance panels, or becoming contracted with insurance carriers so that you can see patients that carry a specific type of insurance? Do you know what it will take to do so? Which carriers do you choose to work with? All of these are important things to consider when you are wanting to become contracted with any insurance carrier. First, you need to think about the which carriers you are interested in joining (Aetna, BCBS, Cigna, Humana, Medicare, Medicaid, united Healthcare, Tricare). Second, you must consider the process you have to go through to become an in-network provider, the credentialing process. This process requires you to; (1) complete either an initial Letter of Intent or application request, (2) complete an extensive, detailed application, (3) complete the CAQH online database, (4) sign and agree to the terms/agreement and reimbursement schedule set forth by the insurance carrier. You can also anticipate your agreement will be renegotiated every couple of years. So what are common reasons providers get denied to join a network:

Incomplete application
Not allowing any more providers in your area of specialty into the network within your geographical area (city, town or county)
Not licensed or registered within the field of expertise that they will contract with
Not contracting with your provider type

So how do you deal with these types of issues? Always make sure you have completely filled out your application, leaving NOTHING BLANK. Or you can always ask for assistance from a company that works with providers through the credentialing process (such as Rill Unique Enterprises). Make sure that you designate yourself within a unique specialty in your area of practice. Double check to see what type of licensing the carrier will accept or if you must be just registered and licensed. If they don't contract with your provider type, do you have other options? If so, what are they? Always make sure to include all additional documentation they request, such as; W-9, proof of liability insurance, and licensing/registration certificates to name a few. The credentialing process can seem 'scary', but if done correctly, the payoff of accepting patients with insurance can be very beneficial to your bottom line.

Mental Health Professionals vs Insurace

10/06/2011 15:01:00

There are thousands of mental health providers who decide to venture out into the world of private practice who are totally unaware of how insurance may, or may not play a part in the success of their firm. Like any other type of provider, you must be aware of the rules of working with insurance as it pertains specifically to your profession.

First, you need to decide what type of insurance may be beneficial to your practice. There are hundreds of commercial carriers (aka private insurance) and state health programs (like Medicare and Medicaid) and even military (Tricare or formerly CHAMPUS). This is crucial when it comes to contracting with these carriers and the credentialing process you must go through to become contracted with them (aka an in-network provider). For instance, if you are wanting to work with state health programs, you have to be licensed at a certain level in order to contract with Medicare and not Medicaid. In addition, there are specific guidelines within an individual's policy that will dictate whether a procedure is covered or not based upon the type (licensing) of the mental health provider they are seeking. For example, the insurance may only cover a procedure completed by a licensed psychologist and not a licensed professional counselor. Keep in mind that insurance will also require you to update, or re-credential at least every two (2) years. You also want to take into consideration what type of patients you see and are able to help; so what services you provide. Do you work with minors, with sexual based issues, with substance abuse issues, with individual or group counseling? This too will be a determining factor of the type(s) of insurance you may want to work with. Upon submission of a credentialing application with an insurance carrier, keep in mind that acceptance is not only dependent upon your qualifications and licensing to complete the job you say you can, but also on where you are located and whether your 'market' is saturated with other providers in your area already apart of that insurance's network.

Once you have gotten past that part, you also want to make sure that you familiarize yourself with basic insurance policy terminology/requirements such as; pre-authorizations, co-payments, deductibles, co-insurance, visit limitations, out of pocket maximums and any exclusions. While it always considered the responsibility of the patient to know this information, so should you to ensure that you are collecting all monies due to you upfront. You don't want to play the chasing game! You also want to make sure that your HIPAA/Privacy Policy is in place, along with your Financial Policy. All should be reviewed and signed by the patient prior to any treatment. Last, how are you going to submit claims and follow up to make sure reimbursement has been received promptly? If you intend to just mail claims in, expect long wait times to receive your payment-between 45 - 60 days on average. If you have the means to submit claims electronically, the preferred and in some case mandated way, expect payment within 20 - 30 days on average. The most sensible option as your business grows and you have less time to worry about claims and follow up is to either hire someone experienced to work in the office with you to handle this, or out source to a reputable billing company. Done correctly, taking insurance can be profitable and very beneficial for you. Always remember, if you're not sure, make sure to ask.

Leaving Money on the Table

09/12/2011 15:38:00

Once you become contracted with various insurance carriers, there are many pieces of working with insurance that you must keep in mind as a provider to make it worth the effort. You automatically agree to the contracted rate or physician fee schedule with the carrier per your contractual agreement, that stipulates how much they will pay you for each particular service that you provide. Although, there are other fees that you want to make sure you also collect so that you are not just leaving money on the table. You want to make sure you are collecting; co-pays, co-insurance and deductible amounts upfront before providing any services to the patient. These are all the direct financial responsibility of the patient(s). Below is a short description of each:

Co-pays - the dollar amount a patient must pay per their policy for seeing a specific provider. This amount usually varies from $5 to $50 depending on the practice type and of the policy outlines. It may be zero too.

Co-Insurance - this is the percentage that the patient is responsible for of the cost of services provided. This amount normally ranges from 10% to 40%, although it could be more. A policy that pays 100% is fully covered and therefore there is no co-insurance. This may also be covered occasionally by a second policy, if the patient has multiple policies.

Deductible - this is the amount the patient must pay out of pocket prior to the insurance carrier willing to cover any cost of services provided. This amount can range from $150 up to $5000 or more, depending upon the patient's policy.

So for example, if your cost of service is $200, then a possible breakdown for total reimbursement for the cost of service may look like such;

Provider Rate from insurance = $40

Co-pay from patient = $20

Co-insurance from patient (20%) = $20

Deductible ($100, with $60 already met) = $40

Total Reimbursement = $120

Based on this example, you can see that you actually receive more than half of what your services cost. The objective of working with insurance is definitely a numbers game though; so you have to average out how many patients you would need to see based on an average of reimbursement obtained to make it work the effort. Yet, the key may very well be making sure you collect ALL of the money due to you, from the insurance and the patient directly!

Credentialing, what is it?

08/24/2011 12:45:00

Medical credentialing is the process of submitting your application to an insurance carrier to participate with them as a new in-network provider. Upon submission, the insurance carrier will verify all information provided, making sure that you as a provider have the required training to practice in your field, have met state and federal licensing guidelines and you carry the minimum liability insurance for your related area(s) of expertise. Once this process has been completed, you will then become contracted with the insurance carrier, agreeing and signing documentation about to the terms outlined by the carrier regarding services rendered, patient treatment restrictions, record keeping, state and federal laws adherence and reimbursement schedules. This process can take anywhere from a few months to over six (6) months, depending on the complexity of the application submitted, the case load of the credentialing department reviewing the application and the saturation of the area where the provider is located. Most carriers now require a universal application to be completed and submitted via the CAQH (The Council for Affordable Quality Healthcare, Inc.). CAQH is a non-profit collaborative alliance of the nation's leading health plans and networks, housing all of the information required related to each provider during the credentialing process. By accessing the CAQH, this helps to streamline the credentialing process for carriers, as well as make it easier for annual or bi-annual required updates. Providers can choose to work through the credentialing process on their own and/or work with a company who specializies in helping them to become credentialed with various different carriers. Credentialing can be done with individual private/commercial insurance carriers, state program (Medicare, Medicaid, CHIP, CHP+, etc), military programs (Tricare) and other health related networks (wellness programs, etc.). Common reasons for an application to be denied are; (1) missing/incomplete information, (2) licensed provider type not allowed to currently contract with the carriers/network, (3) market territory is already saturated by other providers who also provider services to be rendered and (4) lack of required training, licensing or liability insurance.

Time Management-How well do you do?

08/12/2011 11:31:00

In order to run a successful practice, you must make sure that you have effective time management skills. Maintaining a practice entails juggling various parts such as; scheduling and taking care of patients, bookkeeping/record keeping and financial outlooks, claims submission and review, patients account updates and marketing. To ensure that all areas are being covered adequately, time management is the key! Every provider should make sure to implement some type of scheduling system for the practice that outlines when each activity is to be completed and how much time will be spent doing so. Some industries like financial services, are known to use color coded systems that allows for them to quickly see how much time is being spent on each activity and which areas may need more attention. They can also use this system to prioritize their activities too. All in all, each part is essential to the overall success of the practice. Allowing the time, aka planning, to chart your time management so that you know everything is being taken care of and perhaps recognizing when you may need to hire someone or ask for help, can be what ensures that the practice continues to grow, reaching the next level desired. Time management is applicable to everyone in the practice, regardless of the size. Yet, when all employees see how impertative this piece is to even the owner/CEO, they will surely adopt these techniques and apply it to their own duties. The practice as a whole needs good time management, along with each inidividual employee-all together the practice can flourish in ways that you may not thought were even possible!

What are CPT/HCPCS Codes?

08/04/2011 14:01:00

Current Procedure Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Level II codes are used to give a detailed explaination of a specific type of medical procedure completed for an insurance carrier and state offices who collect information on medical procedures. While there are thousands of codes that can be used, you must be very careful to not inadvertantely use an incorrect code or make sure to have the right modifier with the code. A modifier helps to explain the procedure in greater detail, i.e.; right side versus the left side or multiple procedures at one time. CPT/HCPCS codes in combination with a diagnosis code (to be covered in another blog entry), creates the medical necessity that insurance companies thrive on and use to determine whether payment should be made or not. The codes are each five digit, alpha and numeric, in length. Modifiers are two digits, also alpha and numeric, in length. These codes are updated annually by either the American Medical Association (AMA) or Center for Medicare & Medicaid Services (CMS). Insurance companies also determine which procedures are covered according to these codes, by an individual's insurance plan. As long as a medical provider is trained and certified to administer the procedure they have completed, then they are allowed to use that code. Certification may include being registered with the appropiate legal authority within a provider's city/county and state. This does include alternative treatment providers. CPT/HCPCS code books can be purchased from a variety of vendors online, or from the AMA and CMS.

Massage Therapists & Insurance-Possible or Not?

07/28/2011 16:46:00

Massage therapists are often looking for various avenues to increase their patient base and grow their practice. Although most go thru school, graduate and then start their own business, they are unsure about their options for gaining more clients. Many understand that they can have clients pay for their services by cash or charge, yet most do not know that insurance is also an option. How can this be? While it is true that massage therapist are not allowed to contract directly with any health insurance carrier thus far, they are able to contract with a few auxiliary networks that in turn work directly with the health insurance carriers. By contracting with the auxiliary networks they are then able to advertise that, yes they do accept patients with insurance. This capability can help them grow their business tremendously, based upon who their target market is. In addition to accepting health insurance patients, they also have the option of working with auto injury claims and workers compensation. Auto injury claims do not require a MT to contract with the auto insurance carriers. Workers compensation does, and may only allow a limited number of MT into the network currently. Before venturing into the insurance world, it is strongly suggested that any MT review what their end goal is for their business, how much they are willing to do on their own and what type of budget they are working with for marketing purposes. While some of insurance billing can be handled by a single provider, as they grow, they should definitely look to need more help.

Setting Your Practice Fee Schedule

07/20/2011 15:02:00

After completing your formal schooling, obtaining your required certifications and licensing with the appropiate boards, now it is time to open your practice and began acquiring patients. In the process though, have you taken time to complete an assessment of how much money your practice needs to earn monthly, even daily to operate (minimum income amount)? Or how many patients you will need to see each day to reach this mimimum goal? It is possible to complete an analysis that enables you to forecast this information, even before you start seeing patients. Understanding what the mimimum needed to operate the practice is not only allows for you to then set profit goals, but also create an adequate fee schedule that will ensure you are reaching and maybe even exceeding your goals. Just because the insurance carriers will only pay you a set amount, that doesn't mean they also dictate what your fee schedule is. You, as a medical provider, have more control than you may think! While each carrier has their own fee schedule they pay you by, you can decide what 'mix' of patients you need to see per carrier type daily to reach your minimum goal and ultimately, your profit margin. You may also decide that contracting with some carriers is much better than with others. All of this can only truly be determined though, once you have done the proper planning and analysis to determine how much you really need to earn. Stop short changing yourself by simply just guessing what you're worth, and know what you're worth.