Category Archives: Authorizations

Every practice does it…

I was debating continuing the joke into inappropriate-land, but my professionalism got the better of me.

By “IT” I mean, no matter how careful the front desk is, the doctors occasionally see a patient that has an insurance the doctor is not contracted with. If you have a lot of non-contracted patients slipping through, please read my post on how to run a tight ship at the front desk. The purpose of this article is not to cast blame, but to help you deal with the inevitable insurance fight that will result when this does happen.

Just like all posts, this will have a detailed article and a summary wrap up at the end, and a downloadable guide. If you are looking for particular information, try pressing CTL + F and a little search box will pop up. Put a one to two word search query there and press enter. You should jump directly to the part of the post that applies to you.

The BEST case scenario when you end up with an out of network patient, is that they have a PPO, Managed Care (MC), or Place of Service (POS) plan with out of network benefits. The patient will end up paying more toward their coinsurance or deductible, which, you know, sucks for them, but the allowed amount for the provider will be the same as the in network rate.

If the non-contracted insurance is an EPO, the patient has no out of network benefits. No matter how much you appeal, you will not get any payment from this insurance. Now you have to break out your flow chart. If the patient doesn’t have anything secondary to their EPO, you bill them your cash price. Or the full price. Whatever. You do you. If the patient does have a secondary, you send a claim to the secondary with a copy of the primary denial and hopefully you are contracted with them.

Here is where it gets a little complicated. If the patient has a commercial HMO, there are a ton of rules the IPA will cite in order to deny your claim. And, if the patient does not have a secondary insurance, you can decide how much effort you are going to put in trying to get the insurance to pay your claim. You can bill the patient right away or you can appeal the charge to the non-contracted IPA. I, personally, will fight with the insurance company for a couple of rounds before I bill the patient. A patient who has insurance is very unlikely to pay your bill, even if they legitimately owe it. A patient who has an HMO generally has less money in their budget then someone who has a PPO or EPO and is even less likely to pay your statement. Here are your options with a commercial HMO patient.

  1. You are a family practice/internal med contracted with the IPA, but you are not the PCP. Unfortunately, in this case, there is probably not much you can do. You can try sending a claim to the claims department with the medical records and a letter requesting retro authorization. Here is an example of a letter requesting retro authorization. You would update the letter to explain what happened in your case. I have not had much success in convincing the insurance to pay in this situation. Mostly because the IPA has ALREADY paid the other provider their cap for that patient for the month. They are not going to pay you another cap payment, and they REALLY don’t want to pay you fee for service. 
  2. You are a family practice/internal med and you are not contracted with the IPA. You have a better shot in this situation getting a retro auth from the insurance. You would use the same type of letter as in the above example. I have about a 70% success rate when this happens. 
  3. You are a specialist and you did not get an authorization. Whether or not you are contracted, you have about the same chance of getting paid if you did not get a prior auth or single case agreement. You write a letter to convince the insurance that the services were medically necessary, or urgent. 

One of the most complicated situations arises when a patient comes in and hands you a Medicare card, but it turns out they actually have a Medicare Risk HMO plan. If the patient does not have a secondary, you would handle the charge in one of the ways outlined above. However, most of our patients with MR Risk HMO plans, also have Medicaid secondary (called Medi-Cal here in California). If your provider is contracted with Medi-Cal you are not allowed to bill a patient under any circumstances. It does NOT matter that the patient went to the wrong doctor, it does NOT matter that they gave you the wrong insurance, it does NOT matter that they specifically withheld information regarding a primary insurance, it does NOT matter that the insurance they became effective with on the first of the month when you saw them is not one you are contracted with, it does NOT matter that you requested an urgent auth and the insurance denied it. Medi-Cal does not care. My out of state readers will have to let me know if your Medcaid works the same way, but that is how it works here. Also, Medi-Cal has been forcing people into HMOs as well. So what often happens, is that a supposedly straight MR patient comes in, you bill MR and they deny it stating the patient has an HMO. You can’t send that denial to Medicaid because the secondary is also an HMO and you are not the PCP. And, unlike in the previous situations, you are not allowed to bill the patient. 

Here is an example of a letter that I have successfully used to get payment from an IPA in this exact situation. 

I have added all the letters to the links and tools page, and I have created this Downloadable non-contracted patient guide, to help you easily determine what you need to send where in which situation. If you need help with your specific patient, and your specific situation, send me an email.

If your office needs training or consulting or an audit, or if you decide that all of this is too much hassle and you want to pay someone else to do it for you, you can give me a call (909) 374-5439. I am awesome at this stuff. All the partners in New Generation are awesome at this stuff, actually, and we will train, consult, or bill, well, awesomely.

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Filed under Accounts receivable, Authorizations, Billing, Denials, Doctor's Office, Follow up, Health Care, HMO, Medical Billing

The front lines in the battle for your A/R

Your front desk staff are the marines of your office. The doctor is the general, the office manager and billers are the lieutenant and sergeants, and you can’t run a successful campaign without them. But your front desk staff are the boots on the ground, first in, last out. Their actions represent the first impression patients get of your office, and they have the last interaction with patients before those patients leave. I know that mostly, by the time you come to this blog for help, the patient has already been seen and you need to know how to get the charge paid.

But I get your emails, I know what you really need.

In a perfect world, insurances would just pay what they were supposed to, patients would send in their checks on time, and we could all leave work at 5:00. This post will help you get a little closer to that perfect world, and it all begins with your front desk. Many offices, family practice and specialists alike, end up seeing patients with insurance that is not on file, termed, or non-contracted. This happens for a variety of reasons. New patient’s tell us they have PPOs when they really come in with HMOs. Established patients forget to tell us that they changed insurance 2 months ago. HMO patients forget that if they change their PCP, they can’t come to us anymore. Howeever, with the proper procedures, the number of patients with these issues that actually get in to see the doctor can be virtually eliminated. I recently had someone contact me to train their front desk, and this is the checklist that we put together to ensure that the doctor will be paid for every service he performs.

When a patient calls in to schedule an appointment…

  1. New patients – Many offices send patients to complete their paperwork online. If you do this in your office, you only need to get the name and phone number when the patient is on the phone.
    1. Name and phone number
    2. Insurance name and id#
    3. Date of birth
    4. Verify insurance
    5. Schedule appointment
  1. Established patients
    1. We have your phone number as (909) 555-5555, is that still correct?
    2. And we have you with BlueCross BlueShield, is that correct?
    3. Schedule appointment

The day before the appointment….

  1. New patients
    1. Call to confirm appointment
    2. If your patient filled out their paperwork online, verify eligibility
  2. Established patients
    1. If patient has not been seen within 30 days, verify insurance (eligibility, deductible, copay)
    2. Call to confirm appointment
    3. Also, please be aware you have a balance of $XX.00. See you on Friday!

When the patient checks in…

  1. We still have your address as 1122 N. Del Sol Lane, is that correct?
  2. Collect any copay/deductible. If you are collecting toward a deductible, charge $50 and tell the patients this will be applied toward their deductible. Anything over that the insurance applies will be billed to their account. Unless the patient is in for a post-op, blood draw, or follow up for an established condition. In that case, the service the doctor performs probably won’t end up with an allowed amount of more than $50.00. We want to be very careful that we don’t charge patient’s more than the insurance allowed amount when we collect toward their deductible.
  3. Copy any new insurance cards

When the patient leaves the office…

  1. Schedule any necessary follow up appointment.
  2. Collect for any additional procedures performed (cash patients)
  3. Put in for any referrals

I have included this Front desk checklist on the links and tools page for you to download. These procedures are small changes that can have a transformative effect on your office and allow your billers to concentrate on what you pay them for. Namely, fighting with the insurance companies. When your billers have to run around after the front desk and try to solve these issues after the fact, it’s too late. As always, call or email with any questions. I love hearing from you.

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Filed under Accounts receivable, Administrations, Authorizations, Billing, Denials, Medical Billing, Office policy, Office Visit

Medi-Cal and Psychiatry (Tip: It’s a Mess)

If your psychiatrist is contracted with Medi-Cal, you are probably beating your head against your desk in frustration at this very moment. I know I am. This post will attempt to make your life easier and save you the headache when it comes to billing for your Medi-Cal patients.

First things first. Medi-Cal does not cover psych services directly EXECPT when the patient is mentally retarded. That means your claim needs to have an ICD9 code between  317 – 319. If your patient is mentally retarded, you can send a claim directly to Medi-Cal and they will pay you. But only with 2012 codes or office visit codes. Medi-Cal hasn’t updated to the new 2013 codes for psychiatrists.

Treatment for any other diagnosis carves out to the county. Please note, this is NOT the county the patient currently resides in. The claim goes to the county of origin. Which you can find on your online Medi-Cal eligibility verification sheet. If you do not have online access to Medi-Cal eligibility, I suggest you stop reading this post and go sign up. Remember to come back though. The explanation gets more convoluted. Once you’ve determined where the claim should be filed, please also make sure your provider is properly contracted with the individual county plans. If she is a Medi-Cal provider but her Los Angeles County Mental Health contract has lapsed because the office manager did not do the credentialing in a timely manner, your claims will not get paid. For example.

If a patient walks in with a Medi-Cal based HMO such as IEHP or Blue Cross, the claim also goes to the county. However, if the plan is based on the Healthy Families program or a DualChoice program with Medicare and Medi-Cal combined, you would need to call the health plan to determine where to send the claim. And I am sorry, but there is no quick and easy guide for that; the claims address and financial responsibility for mental health depends on the individual plan.

For mentally retarded patients with Medi-Cal based HMOs, the claims STILL go straight to MC. Even if your office manager gets an authorization from the health plan, send your claim directly to Medi-Cal. I have attached a small flow chart  to help you get your claim to the correct place along with a list of county mental health carve outs. Unfortunately, I can only include the carve outs I have worked with.

So, any of you out there with carve out information not on this list, please shoot me a quick email at newgenerationbilling@gmail.com or comment on this post so I can add it. I will add the flow chart and the county carve out list to the links and tools page. Remember, if you are going to bookmark anything, the links and tools page would be the smart way to go.

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Filed under Authorizations, Billing, Claims, County carve out, Doctor's Office, Medi-Cal, Medical Billing, Psych

Psych Secrets

This post is about doing billing for the psychiatrist or psychologist in your life. It’s going to be a long one, guys.

The new CPT codes for mental health services for 2013 are going to have to be a whole post themselves. If you absolutely, positively need an easy explanation before I can get the post up, please remember, you can call or email. The diagnosis that are categorized as mental health conditions range from between ICD9 code 290-319 (ICD10 F01-F99) and if you are not a psych or a therapist and you bill any of these dx primary, you might end up with a denial, so please be careful.

The most important part of the process is the insurance verification. I know that a lot of health plans show the mental health benefits online. Unfortunately, the information they give you online is incomplete, so you are going to be making some calls. The number for the mental health information line is on the back of the card. Also called behavioral health, the people at this number will become your new best friends. Well, at least until you have to call about a claim. Here is where you learn some new terminology. Below is a list of the questions to ask when you’re on the phone with eligibility.

1. Does this plan require authorization?
2. Do the claims carve out?
3. Are there different benefits for parity and non-parity?

A plan carves out when the financial responsibility for mental health services changes from the health plan to another company. For example, Health Net carves out the mental health to CHIPA quite often. So you would send your psychotherapy claim to CHIPA rather than Health Net. You would get your authorization from CHIPA as well. Parity diagnosis are the “serious” ones. I wish I could give you a better definition. Parity dx include most of the chemical imbalances and a few others. Here is the full list, edited for ICD10:

1. Anorexia – 307.1 (ICD10 F50.00 through F50.02)
2. Bipolar Disorder – 296.40 through 296.80 (ICD10 F30.0 through F31.9)
3. Bullimia – 307.51 (ICD10 F50.2)
4. Major Depression – 296.20 through 296.36 (ICD10 F32.0 through F33.9)
5. Obsessive-Compulsive Disorder 300.3 (ICD10 F42)
6. Schizoaffective Disorder – 295.70 through 295.75 (ICD10 F25.0 through F25.9)
7. Schizophrenia – 295.00 through 295.65 (ICD10 F20.0 through F24)

When I was first learning psych billing, I printed this list and taped it to my wall. One of the most useful tools I had.   You also need to know whether you are calling for inpatient or outpatient benefits and substance abuse or mental health. Please remember, all of this information, it is most efficient to get from one phone call. In our office we actually have an insurance verification form that we fill out when we get benefits for new patients. You can use our insurance verification form or you can make your own, but taking a few moments to write down this information saves you from having to call back multiple times. 

Once you have this information, sending the claim out is pretty straightforward. However, if your doctor is contracted with Medicare or Medi-Cal, please give me a call or shoot me an email. There is a LONG explanation regarding getting paid by those companies and it won’t translate well into blog form.

There have been a lot of changes in the psych billing world in the past few years, and it is quite possible that any number of things could have slipped through the cracks in your office. If you still have a lot of money sitting on your AR and your reimbursements aren’t as high as you think they should be,  we can come in and take a look for you, we do that for free. If everything looks fine, we give you a high-five and a few of our cards to pass out to your colleagues. If you do need help, you can hire us to fix it, or we’ll tell you how to fix it yourself. Email me at newgenerationbilling@gmail.com.

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Filed under Authorizations, Billing, CPT, Doctor's Office, Health Care, ICD9, Medi-Cal, Medical Billing, Medicare, Psych