Options for Out of Network Providers

Many providers opt to take the road of staying out of network, or not participating with insurance carriers. This has been going on for many years. Usually it tends to be specialty providers such as mental health providers but with the increasing changes of insurance billing more and more providers are opting to take this path.

What does that mean for the provider and the patient? Well for the patient it means that they need to verify if their insurance provides out of network benefits. If they do have out of network benefits, then the claim may be submitted and payment, if any, will be made directly to the patient. The provider may not necessarily file the insurance claim for the patient. They may simply provide the patient with a statement that will allow the patient to submit the claim themselves. Some, although in our experience, it is rare, actually still submit the claim even if they are not in network. For the provider it may mean that the patient may choose to go to a different provider that is in network with their insurance.

Are there any other options for these providers to assist the patient with the claim submission process while remaining out of network and not incurring expensive overhead costs such as office staff to submit the claims? We actually were introduced to a company that developed a phone app to assist patients with submitting out of network insurance claims! The app which is free to download, allows a patient to take the statement given to them, enter all of the information into the app with just a few questions, and submit the insurance claim to their insurance carrier. Then they receive notifications when the claim is sent, and when the claim is received by their insurance so that they can easily follow up.

The app actually allows providers to register themselves (no charge!) so that if their patients use the app the provider will come up on a search and the patient can simply select them without having to enter the provider’s demographics, NPI or tax ID. They also provide handouts for the out of network providers to give to their patients, or put out in their office to walk the patients through the process. There is even an option for providers to pay a small monthly fee that allows their patients to submit claims using the app at no charge to the patient. So if the provider would like to submit claims on behalf of the patient but they don’t want to have people on staff to handle that, they can incur the cost and it’s much cheaper than having an employee.

This may seem like an odd topic for a billing service to be discussing. After all, we are the ones doing the billing for most providers. However, we often come across a provider that is out of network, and our service really doesn’t make sense for them. Or we all know that patient that has a provider they love, but the provider is out of network and they need to submit the claim on their own. My daughter used to go to an out of network dentist that she absolutely loved. She had a slight fear of dentists and he was amazing. I wish this app had been available back then!

So if you know any out of network providers, or if you have a friend or family member that struggles with submitting their own claims, you can find out more about this program at https://reimbursify.com/

Outsourcing Vs. In-house Medical Billing

 

After 25 years in the business, we still have many people ask us why a provider should outsource vs keeping the billing in house. It is something that new billing services need to understand in order to succeed. If a billing service doesn’t understand their worth then they will never be able to sign up clients. And both new and established billing services need to recognize when a provider’s office has an in house billing system that is working. If they have a billing system that is working and your service won’t benefit them it’s not a good idea to enter into a contract.

In our experience a provider won’t usually agree to sit down with a service if their current system is working efficiently. They usually only meet with an outside service if they have a problem. But it’s important to recognize when outsourcing makes sense. In order to determine if outsourcing makes sense a cost analysis should be done. Here are some things to consider when performing a cost analysis:

1. Billing Department/Staff costs – This would include the salaries of the employees working in the billing department. If there are employees with multiple functions (billing and front desk, etc) then estimate the amount of time spent on billing (50%, 75%) and take that percentage of their salary. It would also include healthcare costs (if supplied), payroll taxes, vacation time, sick time, disability, office space, and supplies (desk, printer, paper, ink, phone, postage, forms, etc). Basically anything that it is costing the office to have the employee in the building.
2. Software/Hardware costs – Practice Management Systems range anywhere from a few hundred dollars to several thousand. This cost also depends on if the provider purchases server software or if they ‘rent’ software monthly. If the software requires updates, or support those costs need to be considered as well. There is also the computer costs, as well as maintenance on the computers. The cost of any printers, scanners and/or photo copiers would also be considered. These items may still be required if outsourcing however the costs will go down because the usage goes down.
3. Claim Processing Costs – This would be clearinghouse fees, envelopes, postage for paper claims and patient statements, and any other costs associated with actually submitting the insurance claims.

Most medical billing services charge a percentage of the amount collected and studies show that the nationwide average is 7%. In some states charging a percentage is considered fee splitting and is illegal. Whether the billing service is charging a percentage or a flat fee, the costs are usually around 7% of the practice’s revenue.

Studies do show that on average the percentage of revenue collected when using an outside service is higher than the percentage of revenue collected in house. In our personal experience we have seen that the providers that switch from in house to using our service have seen increases in their revenue. In some cases it has been a very large increase and in one in particular it was 60 percent.
Studies also show that 25%-30% of medical office revenue is lost to improper billing. $59% of in house billers do not review EOBS and 55% of in house billers do not appeal denied claims. Our experience supports these studies. We find that most in house billers do not run or work regular aging reports and do not appeal denied claims. They simply send out the billing and accept whatever comes in. Most medical offices have a high turnover of staff and the providers are not involved with the billing so they are unaware of the amount of revenue being lost.
If considering outsourcing a provider should look at all of the costs to billing in house, what their current average revenue is, and how much it would cost to outsource. They should also consider how much they are collecting of the amount being billed out to see if there appears to be an issue. If the in house billing system does not seem to be efficient or effective outsourcing may be a good move. Next newsletter we will go over what a medical office should look for when interviewing a medical billing service.

3 Key Strategies to Improve your Revenue Cycle Management for Patient Responsibilities

With patient deductibles and copays being higher than ever it is important that providers have efficient and effective systems for collecting what is due. There are many different elements involved with patient care and the billing of patient care. It is like a machine with a lot of moving parts. If one part isn’t moving properly it can mess up the entire system. Here are three key strategies to help improve an office’s efficiency and effectiveness of collecting the patient responsibility for their services.

1. Automate – Believe it or not there are still providers out there who do a lot of their revenue cycle management by paper. With the technology we have today that is hard to believe but we are in offices all of the time and we are still seeing providers with paper systems. One of our offices doesn’t have internet connection on their front office computer and the PM system is from 2004. It is near impossible to have an efficient and effective paper system. It may be effective but it won’t be efficient. You don’t have to break the bank to automate. There are many affordable options out there. Revenue cycle automation can significantly reduce the administrative burden on an office.

2. Improve Front-end Processes – Errors on the front end cause a ton of work on the back end. There are a lot of things that can be done on the front end to prevent errors that will save a lot of work on the back end. It is estimated that approximately 90% of claim denials are preventable. Most of these denials could be prevented with good front end processes in place since missing or incorrect patient data is one of the main denial reasons. Making sure the patient’s data is accurate when collected is one huge way to prevent denials. Claims that are denied often go unpaid which prevents the provider from not only collecting anything due from the insurance carrier but also from the patient. Automating patient registration, benefit verification and prior authorizations can greatly improve accuracy of claims.
3. Improve the patient billing process – Many offices do not even send regular patient statements. Patient statements should be sent at least once a month. Technology today can allow an office to send patient statements by email which can cut down on costs tremendously. It cuts out printing costs, postage costs, and supplies such as paper and envelopes. It also saves on time in stuffing the envelopes. There are also services out there that can receive patient bills in a file and they print and mail them. Usually their cost is less than it costs an office to mail the statements and they provide a lot of options such as statement layout and customization.

With the patient responsibilities becoming larger and larger it is crucial that providers are able to collect on those amounts due. Implementing procedures and systems to make the process more efficient will help cut down on amounts becoming uncollectable and will improve the provider’s overall revenue management cycle. Technology can help to bring the revenue cycle up to speed in an evolving industry.

 

 

Update on Clearinghouse Switch

 

 

We just wanted to give everyone an update on our clearinghouse switch.  Just a quick recap:  We had been using Office Ally as a clearinghouse for the past ten + years but they announced a change in their pricing effective February 1, 2019 that would have created an increase of over 10000%.  Instead of $20 per month we would be paying $2000 per month.  Obviously that wasn’t going to work for us so we found a new clearinghouse.  We switched to Claim.MD and our monthly fee is only about $200.  We currently are billing for about 50 providers all across the US.

 

We switched to Claim MD on February 1st and we’ve had many people asking us how it’s going.  Well it’s only been just under three months but so far we are thrilled!  Quite honestly I do not like change so I was not looking forward to this.  However, the change was really not that bad.  Considering we have 50 + providers that’s huge.  I’m not going to lie, for that many providers the EDI enrollments for Medicare and Medicaid got a bit intense.  But Claim MD makes it as easy as possible.  We made it through without too many bumps.  Once we got over the initial shock of the change and started looking around we were pleasantly surprised.

 

Claim MD has many features that we really like.  The rejected claim section is awesome.  They have a dashboard that tells you how many claims are out there, and then you can go in and make corrections and resubmit.  Initial rejections as well as ERA rejections are all in the same place and easy to access.  The ERA section works great.  It’s so easy to retrieve an ERA when needed.  Signing up for ERAs is very simple.  Really everything is totally simplified.  We have 8 people who upload claims into the system and ClaimMD makes it very easy for me as the owner to see a good overview of what everyone is doing.

 

There is also a feature that allows us to check eligibility right from the rejected claim by simply clicking on the patient.  It saves us from having to log into another website and reenter the patient information.  We are still learning about the system and I’m sure we haven’t taken advantage of all that they offer, but right now we are thoroughly happy with our switch!

 

New Way to Bill for Extended Couples/Family Sessions

Barbara Griswold, LMFT sent us a great article recently.   She wrote about billing for couples and family sessions, and she has given us permission to share it with you.   She writes…

As an insurance billing consultant, one of the most frequent questions I receive from therapists all over the country has been how to bill for couples and family psychotherapy sessions that are longer than a routine 45 to 60 minute session.

Therapists find longer couples and family sessions beneficial for a variety of reasons, such as being able to do more in-depth assessment and treatment, to have more time to work with a high- conflict family and resolve conflicts in session, to allow for a larger number of session participants, or for certain treatment types such as Gottman Method Couples Therapy.   In addition, when clients are not able to come regularly or must come from great distance, longer sessions allow more to be accomplished in fewer sessions.

So, what billing code should be used for extended family or couples sessions?  The American Medical Association (AMA) clarified in 2016 that CPT codes 90832, 90834, and 90837 were individual therapy codes, and should only be used for a family session if a family member comes once or occasionally into a session where ongoing individual therapy is taking place.  In that case, the family member would be serving as an “informant”  to the individual treatment, or might be receiving a summary of the individual’s progress.  In addition, the identified client who is the focus of the individual sessions must be present for a majority of the family session. This ruled out the use of 90837 for ongoing  family or couples sessions, leaving only two CPT billing codes for these sessions — 90847 (couples or family therapy with the client present) and 90846 (without the client present) — which they clarified were 50 minutes each.

A new billing possibility for extended therapy sessions emerged in 2016 called Prolonged Services codes.  These two codes — 99354 and 99355 — had previously only been allowed for use by medical providers when a visit had extended beyond the typical length for that service.  In 2016, the AMA allowed these Prolonged Service codes to be billed with one therapy code: The 60-minute individual therapy code 90837.

But here’s the good news:  As of January 1, 2018, the AMA extended the use of these codes to the 90847 couples and family therapy code. 

To bill using Prolonged Services codes, a few rules apply:

  • The session must be a minimum of 30 minutes beyond the original code.This means, for use with a 90837 (60-minute individual session code) the session minimum would be 90 minutes; since the 90847 couples/family session code is 50 minutes, the extended session must be a minimum of 80 minutes.
  • Billing  requires the use of multiple CPT codes for the same session, each code having its own charge chosen by the therapist.  Thus, multiple lines for the same date of service will be used on the claim form or statement.
  • Prolonged Service codes are “add-on codes,” which means they cannot be billed alone, and must always be billed together with the 90837 or 90847.
  • When used, the 99355 must always be billed with the 99354.

Below are two charts, the first showing how to bill for extended individual sessions and the second for extended couples and family sessions. Note that the time ranges are slightly different since the initial codes 90837 and 90847 vary in their time length.

 

 

 

 

Will insurance plans reimburse for Prolonged Service Codes?  When using these codes, it is recommended that coverage be verified in advance with each insurance payer, checking each client’s specific plan as well as whether they are reimbursed for your license.  Some therapists who have used these codes have happily reported that they were reimbursed for the Prolonged Service add-on codes; others have stated they were reimbursed only for the initial 90837 or 90847.   Thus, it would appear that there is nothing to be lost by utilizing these add-on codes on a claim, invoice, or superbill.

Have you tried billing for these codes?  Let me know which codes you used, what insurance companies were billed, whether they paid, your license, and your state.  Thanks!

 

Barbara Griswold, LMFT is author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance – And Whether You Should, now in its 7th edition.  In addition to her practice in San Jose, CA, she provides consultations about insurance, progress notes, practice building, and difficult cases.  Visit her website at www.theinsurancemaze.com to read other helpful articles, schedule a consultation, or subscribe to her mailing list.

 

Clearinghouse Fees Up 1000% February 1

I write this article with a heavy heart. We’ve been using Office Ally as a clearinghouse for over 10 years. For most of that time we didn’t pay anything. In most recent years we paid a monthly fee of $19.95. But as of February 1st their pricing has changed. They are now charging $35 per month per NPI/EIN combination. $35 is a reasonable monthly fee for a provider’s office. But for a billing service it can prove to be pretty steep.

For the providers that we bill for we will end up being charged over $1800 per month. That’s almost a 1000% increase. For our larger accounts the fees are fine, but we bill for several smaller providers. Some work only part time and we only charge them between $200-400 per month. With the other costs of doing business it isn’t profitable for us to spend $35 just on claim submissions.

I can hear Linda Walker now: “That’s why I use the provider’s software. I don’t incur any costs for clearinghouse fees.” Love you Linda! We do have some clients that we have that set up with. But the majority of our clients we use our system so the clearinghouse fees fall on us. That hasn’t been a problem until now.

So it is with a heavy heart that we are telling everyone that after 10 years we are being forced to switch clearinghouses. We have found another one that the fees are much more reasonable. We have begun the switch but haven’t actually used it yet. It looks like a pretty good system so far so we are actually excited about giving it a try. We were very happy with Office Ally. Their system and their support were great. But as with everything else in life, change is inevitable. We will keep you posted!

Marketing A Medical Billing Business

 

 

Marketing a Medical Billing Business is a huge part of starting a medical billing business.  From our experience it is the most difficult part of getting a new business established.  Many very competent billers may start a business but struggle with finding clients.  If they don’t find the clients, their business never takes off.

 

This is our 24th year of running a medical billing business so we have found new clients many different ways.  We did have a difficult time getting started back in 1994.  We did not realize how hard it would be to obtain clients and we were shy and didn’t like talking to doctors.  We were hesitant to tell providers what a good job we could do.  Fortunately we were patient and stuck through the hard times.  When we look back today over all the different ways that we have found new providers to work with we are surprised at all the different ways providers have found us.

 

We started out doing mailings.  They don’t require you to talk to anyone so it works well for the shy person.  The downside is that the results of mailings are pitifully small.  If you get one or two responses from 100 letters, it is good.  Those are just responses, not accounts.  Now you still have to sign them up.  We quickly found out that we would have to find other ways to find providers or we would starve.

 

Many of the people we talk to think that if they build a website they will find providers.  We have signed up a few clients as a result of our website but if we had to wait for those people to find us we wouldn’t have survived.  We found the accounts we have worked with over the years in a large variety of ways.  My point is that if you are marketing your medical billing business you need to try many different ways of marketing.  You never know which effort will deliver you a new account.

 

One of our first larger accounts we found by answering an ad in the newspaper for a medical biller.  Michele answered an ad that said to stop in the optometrist’s office with a resume.  They were not aware that there were services available but it was a great solution for their office.  23 years later we are still working with them.

 

When NPI numbers were first required we had to obtain them for all of our providers so we wrote a few articles about NPI numbers and posted them online.  We offered to obtain an NPI number for providers  that we didn’t work with for $29.95.  We still get calls today for NPI numbers and still charge $29.95 for obtaining them.  At first we were surprised that after obtaining the NPI for the provider we were asked if we knew where they could find a biller.  We have signed up many accounts over the years after getting them an NPI number.

 

We found a very small account early on who was a social worker.  We worked for her for several years when she referred a family doctor who was a patient of hers to us.  The family doctor is still working with us 20 years later.  Over the years many of our accounts came from referrals.  Referrals are a great way to grow your business but you have to make sure you are doing a good job with the accounts you have to earn a referral.

 

Make sure you reach out in many directions with your marketing.  You never know where the next lead will come from.  You must be determined if you are to succeed.  It is important to recognize how difficult marketing can be so that you don’t get discouraged.

 

 

 

 

Contracts Between Providers and Medical Billing Companies

Anyone starting a medical billing business often looks for a sample contract online to use as they market their first clients.  They really don’t know where to start and feel that a sample will help them figure it out.  The problem with this is that there are so many things to consider when writing a contract that they can’t all be covered by looking at sample contracts.

Our first contract was one page that basically said that we would complete the work within a reasonable time frame and how much we would get paid.  We felt that if a relationship with a provider wasn’t working out we didn’t want to be working for them anyway.  As we grew and gained experience, we saw the need for much more to be included in our contract and we understood why it was important to be very clear with the terms of the contract.

Why do you even need a contract?  Can you just start doing the billing for a provider without a contract?  That would be very unwise.  Contracts spell out exactly what is expected of each party and what the consequences are if these expectations are not met.

What are some of the things that need to be included in the contract?   It needs to be very clear as to what services the biller is providing.  Are you offering full services?  What is included in that?  Are you simply submitting the claims or are you tracking them and resubmitting problem claims and filing appeals when necessary?  Do you charge a set up fee?  Will you be helping the provider with their credentialing needs, coding, patient billing, working aging reports and negotiating contracts?  These are just examples of a few of the services that need to be considered.

What are you charging the provider for your services?  How is the provider going to pay you?  Are they paying you a flat fee, a per claim fee, or a percentage.  If you are charging a percentage, what is the percentage based on and is it legal to charge a percentage in your state.  When is the payment due and what are the consequences if not paid on time?

What is the length of time a contract is in effect?  What happens when that time frame expires?  Can the contract be broken prior to the the length of time designated in the contract?  What reasons would constitute the breaking of the contract?

Confidentiality must be covered.  Patient information must be kept confidential as required by HIPAA and this should be covered in the contract.

This list does not cover all the things that must be covered in a contract but I hope it gives you an idea of how important it is to really spend some time developing a good contract that will hold up in court if necessary.  Unfortunately this sometimes happens even in the most well intended relationships and it is best to have it all fully explained.  If you need more help with your contract, we recommend our ebook “How to Write a Kick Butt Contract for Your Medical Billing Business”

 

PQRS Gets More Complicated

 

We are hearing that many providers are receiving letters stating that they are being penalized for not meeting the requirements of PQRS even though they thought they were reporting correctly. These providers report that they have been using claim based reporting all year on all Medicare claims but are now told they do not qualify.

It seems that the PQRS reporting rules are more difficult, and in some cases even impossible, to follow. For example, we have several LCSWs who report on depression screening and elder abuse. They report on every Medicare patient they see so they are definitely over the 50% mark. However they only report on those two measures since those are the only two applicable ones for their situation.

They too received notice that they did not meet the PQRS reporting requirements. We contacted the PQRS help desk and we were advised that the codes used by the LCSWs, 90791, 90834 & 90837, are eligible for reporting 8 measures and that all 8 measures must be reported. One of the eight measures is body mass index. Most LCSWs are not qualified to discuss BMI with a patient since their BMI may be affected by other medical health issues and/or medications they may be taking for health issues and the LCSW would not be qualified to discuss that with the patient.

Another one of the eight measures is blood pressure. Again, LCSWs are not trained to take and/or monitor blood pressure on patients. Most patients who see LCSWs go there to discuss issues in their life, not to have the LCSW discuss their blood pressure, medications, or BMI. The only recourse is to file an informal appeal. We have done that on behalf of several providers stating that the requirements are not within their scope of practice. It is unfair that LCSWs are going to be penalized for not reporting on measurements that are not within their scope of practice.

The eight measures that must be reported by a LCSW are Body mass index, Hypertension, Alcohol, Tobacco, Pain Assessment, Medications, and Elder Abuse.

While most therapists are likely to discuss depression and possibly elder abuse we have to wonder what hypertension, body mass index, tobacco, etc have to do with the therapy for a patient who is suffering from anxiety. And how is a social worker going to assess the medication needs of a patient they are counseling for problems at work. And yet all eight screenings are required in order to meet the PQRS requirements. Does it make sense? We are closely watching to see how MACRA ends up working out.

 

Over the 24 years we have been in business we have learned many things and found various ways to improve our business. A few of these lessons have made a huge difference in the success and direction of our business.  There was no handbook available (nor is there now) on how to run and grow your medical billing business.  We learned by trial and error.  But many of our lessons came as a complete surprise.  Things happened that we thought would make a huge difference to us and it turned out the opposite.  Small things that happened turned out to be huge.

We find our readers love to hear about issues we have gone through, how we handled them, and how they turned out.  So we decided to write about the three things that have happened to us that really turned our business around.  This month we will tell you how getting rid of our office manager made us much more profitable and
turned our business around.

Michele and I are very easy going.  We don’t like confrontation.  We had gotten to a point where we didn’t want to handle all the issues that come up with hiring three employees so we hired an office manager thinking it was going to end all our problems and allow us to get back to the job of running the business.  Unfortunately we kept this office manager long after we knew we she needed to be gone.  You aren’t going to believe this but we had to hire an executive assistant to get rid of the office manager.

When we brought in the assistant she assessed everything that was going on in the entire office and saw that the office manager was the problem.  She just kept confronting her on what she was actually doing – what work was she accomplishing.  We didn’t realize that the office manager was really doing almost nothing except causing problems.  When she realized this was discovered she called our largest account and made a deal with them and turned in her notice to us.  She went to work for our largest account and within a few months they left us to let our former office manager handle the billing in their office.   Many lessons learned here.

Michele was quite worried over the workload that she would have to take over with no office manager any longer.  It was a very pleasant surprise to find that there was no work load to take over.  The new assistant took care of the employee issues and we took back over the end of month billing and everything went much smoother.  Our phones stopped ringing as much with problems from our providers.  The fires we were always putting out stopped.  We couldn’t believe how much difference this made.  Life was much better.  We also figured out that we did need an office manager, we just had the wrong one.  Hiring the right people for the job is huge.

Next month we will tell you about what else happened as a result of this situation that made our business even better.