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

Online Class Schedule July – Sep

I have about 35 webinar topics and in the past I have offered them consecutively so that I could offer you guys the widest range of information. However, I received several emails from readers telling me that they had missed the class they needed and they would like to know when was it coming back up again. 

It turns out that “next year” is the wrong answer. 

So, here is the schedule for the next three months. My two most popular classes will be repeating, and I have five new topics. If you miss the class you needed, send me a note or give me a quick call. I will be happy to arrange a special class for you or your office. Also, here is the link to my previous topics. If you would like a special class on any of those topics as well, we can set that up. 

Here you are: 

Date                                                                              Topic

July 1st                    Common medical terminology and basics of billing

July 15th                 Timely filing and follow up

July 29th                Technology: Making it work for you and                                                                   safeguarding your data

August 12th          The global period and modifiers 24, 78, and 79

August 26th          Billing for immunizations and J-Codes

September 9th     Psych billing – Parity, Carve Outs, and how to verify

September 23rd   Maximize per patient reimbursement (Family                                                         Practice/Internal Med)

Space is limited. Each class has spaces for 10 people so that everyone can get a chance to participate in the question and answer portion of the lesson. Each class is an hour long. The classes are comprised of 30 minutes of instruction and 30 minutes to answer questions. I have learned to leave the question and answer period long so that I can address questions about how the topic applies to your situation and your specific practice. Please call (909) 374-5439 to reserve your spot. 

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I am going to save you six hours of phone calls to insurance companies. Aren’t I wonderful?

One of our providers recently moved. Those of you who have gone through this can commiserate with me.

Six hours of phone calls,faxing, and emailing later, her address was updated with the insurance companies. Mostly.

So, I am going to give you the results of our efforts in blog form and again in spreadsheet form. Yay, spreadsheets! If any of you out there have other contact info for the provider relations/ credentialing/provider demographic update departments for any other insurances, please leave a comment or shoot me a quick email.

Medicare and Medicaid require that you send them an application form to update your servicing location. If you are an individual provider, send Medicare a cms855i and if you are a group, send in a cms855b. If you don’t know whether you are an individual or a group, call provider enrollment. For Medicaid, I suggest calling your individual state Medicaid and having them direct you to the proper form. I also put the Medicare forms on the new and improved links and tools page.

The rest of the insurances simply need an updated W9 form.

Aetna – Update on Aetna.com. Here is the direct link: http://www.aetna.com/docfind/custom/provider/data_correction.html

Blue Cross – Fax W9 to (818) 234-2836, attn: Anthem Provider Database Management.

Blue Shield – Fax in a W9 to (916) 350-8860, attn: Blue Shield Provider Contracting

Caremore – Fax W9 to (562) 977-6141, Attn: Caremore

Cigna – Email attached W9 to intake_pbm@cigna.com, subject line: Provider Practice Address Change

Health Net – Fax form to (877) 897-7910, Attn: Health Net PDM

IEHP – Email the provider Service Representative for your city. You will need to call them and get that info. The only one I have is for Montclair, CA and that probably won’t help most of you.

Inland Valleys IPA – Fax in your W9 to (213) 830-1815, Attn: Inland Valleys IPA

ProMed/Upland Medical Group – Even if you have more than one IPA contract with a group that ProMed administers, one fax will update everything. So, fax the W9 to (714) 667-8156, Attn: ProMed

United HealthCare – You can either fax or email the update. The email is phshpdemo@uhc.com and the fax is (855) 314-6844

I have also included all this information in beautiful spreadsheet form. Here is the Health plan updates spreadsheet.

You’re welcome  🙂

As always, if you have any questions or anything to add, email or comment.

 

 

 

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Filed under Billing, Doctor's Office, Medical Billing, Office policy

NDC Numbers

So, I just learned something today. About NDC numbers. 

When the NDC number from the label of our medication was not 11 digits, I would add a zero in front of the NDC number when I set up the codes in my system. Recently, I have been having issues with Blue Cross and the NDC for Avastin; they keep sending me rejections stating the NDC is not correct. I checked and double checked on the label of the bottle of medication in the doctor’s fridge that the NDC number I used was correct. A couple of LOOONNNG, irritating phone calls with Blue Cross and some judicious Googling later, I have found the answer. 

The zero does not always go in front of the number. Sometimes it goes in the middle of the number and sometimes it goes at the end-ish of the number. And yes, sometimes we have to add one in front. It depends on how the digits of the NDC number are grouped and where the dashes are placed. Here is the breakdown:

10-digit format:                              Add zero  

4 digits-4 digits-2 digits           1st position – Example: 01111-2222-33       Example: 1111-2222-33

5 digits-3 digits-2 digits           6th position – Example: 99999-0888-77  Example: 99999-888-77

5 digits-4 digits-1 digits            10th position – Example: 44444-5555-01  Example: 44444-5555-1 

Here is our real world example. My NDC number for Avastin is 50242-060-01. I had been sending it to Blue Cross with the zero in front. But the correct format is 50242006001. Please remember, most clearinghouses will reject an NDC number if you put the dashes in. I am refiling so, so, so many Avastins to Blue Cross now. Wish me luck. 

 

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Filed under Avastin, blue cross, Medical Billing

Why you are out of network for Covered CA

I have two providers who are both out of network for the Blue Shield Covered CA Silver plan. They were both surprised and displeased by this. And so were their patients. As a result, I was tasked with “looking into this, please.” Which, as an aside, I was happy to do, seeing as it is my job.

So, it turns out, the first provider was out of network with the Blue Shield Covered CA Silver plan because in late 2013 when he was sent the application for the three tiers of Covered CA plans, he chose to sign up with only the platinum and gold plans, and specifically opted out of the silver plan. Then he promptly forgot that he signed that paper and in Jan 2014 when he started seeing Covered CA people, Blue Shield told Silver patients that he was a provider. They came to him and he saw them and then they had 50% coinsurances applied to every visit. And no one was happy.

Since I learned my lesson with that situation, when it came time to contract the second doctor in this story with Blue Shield, I MADE SURE to check all three boxes for all three tiers of the Covered CA plans. So, at the end of 2014 when he started seeing Covered CA people, Blue Shield told Silver patients that he was a provider. They came to him and he saw them and then they had 50% coinsurances applied. When I called Blue Shield with a copy of the application in my hand the provider enrollment representative told me that since the HOSPITAL my doctor had rights in was not contracted with the Blue Shield Covered CA Silver plan, Blue Shield could not give him a contract that included that plan.

So, if you are having issues with large deductibles, large coinsurances, and your claims are being processed as out of network, call provider enrollment. The issue is probably either something that seemed insignificant and has been forgotten, or completely out of your hands, and something the doctor needs to address.

The contact info for Blue Shield provider enrollment is (800) 258-3091 or BSCproviderinfo@blueshieldca.com

 

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Filed under Billing, Blue Shield, Contracting, Medical Billing

Public service announcement on immunizations

There is only one immunization ICD10 code now. The code is Z23. The description of the code is “encounter for immunization.” You no longer have to specify what vaccine or whether it is oral or intramuscular in the diagnosis code.

For those of you using keywords to search, I am here to help. For my subscribed readers, sorry if this seems repetitive. When searching for the ICD10 replacement for a specific ICD9, your search engine will pick up the terms from this post and you will be able to find what you need in a way that wouldn’t be available with just the new code.

If you are billing a flu shot, use Z23

If you are billing a pneumo, use Z23

If you are billing Hep A or B, use Z23

If you are billing DTap, TDaP, Tetanus alone, or DT, use Z23

If you are billing polio, MMR, varicella, or Hib, use Z23

If you are billing HPV or meningococcal, use Z23

As always, if you have questions or have suggestions, call (909) 374-5439 or email newgenerationbilling@gmail.com, or both. 

 

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Online Class Schedule

If you’ve checked out our pricing and information page, you know we have online classes available for $30 per class. In the past, I was having people call me to get the schedule, but as it turns out, that is really annoying for you guys. You would like to know why I can’t just post it on the blog. You make a very good point. So, here is the schedule for the next three months.

Date                                                                              Topic

February 5th           Billing Blue Cross/Blue Shield out of state plans in CA

February 19th          Common medical terminology and basics of billing

March 4th                 Medical necessity – What it is and why you care about it

March 18th               The global period and modifiers 24, 78, and 79

April 1st                     Reports to manage the health of your practice

April 15th                  Tips and tools for your front desk

Space is limited. Each class has spaces for 10 people so that everyone can get a chance to participate in the question and answer portion of the lesson. Please call (909) 374-2581 to reserve your spot. 

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Filed under Medical Billing, Online classes