Healthcare from the Government – Your Biggest Payer, Part 2

Healthcare from the Government – Your Biggest Payer, Part 2

Medicare is the biggest government payer practitioners will deal with, but it’s by no means the only one. Government-operated health insurance encompasses many other programs and in this second of a two-part series, Nitin Chhoda addresses other government-sponsored insurance plans.

healthcareHealthcare insurance programs operated by the government provide coverage for veterans, low-income adults and injured workers.

Managed by the federal government, some programs are administered at the state level.

All have very specific regulations and can require pre-authorizations, referrals, and proof of medical necessity before they approve reimbursements.

Medicaid

Next to Medicare, Medicaid is one of the best known healthcare insurance programs in the U.S. Designed to provide the poor and low-income individuals with basic health services, it’s administered at the local level. Each state has considerable leeway in the manner in which it administers the program, determines individual eligibility, and what services are provided.

Funding cuts to Medicaid at the federal level has resulted in many states limiting coverage to the most basic levels for adults. The program also provides limited  healthcare coverage for those who require nursing home care. Children in the program receive dental and vision services, along with healthcare. Medicaid patients are entitled to surgical procedures, inpatient hospital treatment, and prenatal care.

It’s extremely difficult to verify a patient’s Medicaid eligibility, what portion of the bill the client may be responsible for, and what services are covered until the actual reimbursement claim is submitted. Medicaid maintains a stringent fee schedule, regardless of actual costs.

Tricare

Funded by the U.S. Department of Defense, Tricare is the healthcare plan that serves active military personnel and their dependents. Tricare encompasses three levels of care – Standard, Prime and Life. Tricare Standard is for active duty, retired and reserve retirees, and their family members. It operates similar to a PPO. Recipients are required to pay a deductible and copay, but can see any civilian healthcare provider.

Tricare Prime resembles an HMO and serves the same segment of the military as the Standard. Patients have more restrictions and must only utilize network providers. Tricare for Life is a supplement plan for former Tricare members that are eligible for Medicare. The plan pays according to a fee schedule similar to Medicare.

CHAMPUS VA

The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) serves VA patients and those not eligible for Tricare, along with spouses and dependents of military personnel who were disabled in the line of duty. Surviving spouses and dependents of veterans killed due to military-related injuries are also eligible.

CHAMPUS healthcare plans are usually secondary payers. When it’s the primary payer, the plan functions much like an HMO. It’s imperative that coverage is verified prior to the client’s visit to ascertain if a referral or pre-authorization is required before treatment is provided.

Workers’ Compensation

Administered by the U.S. Department of Labor, Workers’ Compensation is available for workers injured while on the job or who develop an occupation-related disease. Practitioners must enroll in the healthcare program and obtain a DOL number.

Workers’ Comp claims always require pre-authorization, but that doesn’t guarantee payment for services.

Before treating a client, verify pertinent information about the disease or injury with the employer. A diagnosis code must be approved by the Workers’ Comp carrier and the medical provider must prove medical necessity.

healthcare programClinicians should obtain a pre-authorization for every procedure. Workers’ Compensation claims are paid according to a healthcare pre-determined fee schedule, and funds deposited through electronic fund transfer.

Patients covered by government-operated healthcare programs can add significantly to the revenues of any practice, but clinicians should exercise caution especially with their medical billing and make sure to verify every aspect of the client’s coverage prior to treatment.

Government healthcare plans have numerous rules, regulations and filing requirements and if they’re not followed to the letter, reimbursements won’t be forthcoming.

Medicare: The Government – Your Biggest Payer, Part 1

Medicare: The Government – Your Biggest Payer, Part 1

Clinicians will contract with many commercial insurance providers during their careers, but the heavy hitters of reimbursements are government-backed insurance plans.

In this informative two-part series, Nitin Chhoda examines programs operated by the federal government and what practitioners should know about them.

MedicareGovernment-operated healthcare programs encompass Medicare, Medicaid, Workers’ Compensation, CHAMPUS and Tricare.

Of all the government-run insurance plans, Medicare is the largest and is comprised of four types of coverage, Part A, B, C and D.

Participation is mandatory for some portions and voluntary for others, leading to confusion for patients.

Congress dictates how Medicare claims are paid. Reimbursement requests must be submitted within a specified time frame and the agency prefers to pay providers via electronic fund transfer.

It’s critical for practitioners to verify which Medicare elements a client participates in before services are rendered.

Medicare Part A

The first part of Medicare coverage pays for inpatient care in hospitals, skilled nursing facilities, home healthcare and hospice, but an overnight stay in a hospital is no guarantee of payment. Clients must meet specific requirements for Medicare to pay for inpatient services.

Medicare Part B

The B portion of Medicare coverage is designed to pay for services, treatments and procedures that are medically necessary. Included are services by physicians, home health services, durable medical equipment and outpatient visits. Some preventative measures are covered, including vaccines.

Part B is optional, but those who don’t enroll according to government guidelines are penalized. Patients often believe they’re automatically enrolled when they retire and are dismayed to discover they have no coverage. Recipients also have an annual deductible and pay a 20 percent copay for services.

Medicare Part C

Part C, also known as Medicare Advantage, is an insurance replacement plan offered by private companies that have been Medicare approved. Part C is favored by individuals who prefer private insurance coverage. Depending on the provider, plans can require beneficiaries to pay out-of-pocket expenses, obtain referrals, and only see network providers.

Replacement plans can be used to cover Part A and B services, and some plans include medication and vision coverage. To avoid medical billing reimbursement difficulties and appeals, always verify the client’s coverage, restrictions and limitations prior to treatment, along with the plan’s fee schedule to determine if it differs from Medicare standards.

Medicare Part D

The Medicare prescription drug plan is Part D. While Part D coverage doesn’t typically cause a problem for medical professionals, a large number of Part D recipients mistakenly believe they’ve enrolled in a Medicare supplement policy. Practitioners may find they’re spending a significant amount of time explaining the difference to their patients.

Medicare Supplement Plans

Patients can enroll in a Medicare supplement program, also known as Medigap plans, to cover the costs that Medicare doesn’t pay. It provides a source of secondary coverage, but doesn’t include any non-approved Medicare expenses. Always verify secondary coverage prior to any patient encounter.

Medicare coverageMore than 50 million people age 65 or older and younger individuals with disabilities have some type of Medicare coverage.

It represents a large population of patients upon which practitioners can draw that are covered by a reliable payer.

Incentive payments may also be available for clinicians practicing in geographic areas with a demonstrated shortage of medical professionals.

Insurance: The Rules, Regs and Who Makes the Decisions

Insurance: The Rules, Regs and Who Makes the Decisions

The rules governing healthcare insurance procedures are as varied as the companies that offer policies. Payers may choose to follow the same regulations as government backed insurance plans, while others have developed their own unique set of parameters.

It’s essential for billers to be familiar with them all and electronic medical record expert (EMR), Nitin Chhoda, has released new data on who makes the rules that govern reimbursements.

insuranceWho Controls The Purse Strings?
When it comes to clinicians being reimbursed for the services they render, practitioners should never forget that insurance companies are firmly in control of the entire process.

Each payer has its own set of policies, procedures, manuals and submission requirements. The payer establishes the rules and regulations that medical billers and coders must follow to ensure clinicians are reimbursed.

Practitioners typically contract with commercial insurance companies to reimburse them when one of their covered clients seeks medical attention. Most individuals have insurance through their employer and the payer underwrites the plan, complete with financial caps, treatment limitations and the need for prior authorization and referrals.

Networking Opportunities
Insurance companies control access to providers through the employment of networks. The insurance company maintains a network of medical providers with which it has a contract. The arrangement ensures a steady stream of patients for practitioners.

In return, the clinician agrees to receive specific reimbursements for services to limit outlays by the insurance company.

Contract Specifics
Contracts define time limits for submitting claims, how long the insurance company has to pay the claim, and the type of plans included in the agreement. Fee schedules, procedures that require preauthorization or referrals, and the appeals process are clearly spelled out.

Other payers choose to adhere to the fee schedule set forth by Medicare, modify the fees to pay 110 to 125 percent of what Medicare reimburses, or even pay less. Even though the medical provider may receive less than the Medicare fee, insurance company executives know that patients covered under their plans represent a substantial client base.

The Path to Payment
Most claims result in prompt payment, but the potential always exists for the payer to repudiate a reimbursement. Practitioners must use caution when negotiating contracts with payers, be cognizant of the terms, and long-term implications. Appeals can be filed when necessary.

Much of the reimbursement process relies upon the medical billing and coding specialist entering the correct codes, and ensuring documentation complies with the payer’s submission specifications.

insurance guidelines

Payer-practitioner contracts should be loaded in the practice’s EMR software to facilitate clean claims.

Insurance companies call all the shots when it comes to reimbursements. Clinicians must be vigilant when negotiating contracts with payers to ensure they’re receiving the best return for their services.

A great many payers exist, each with its own set of rules, regulations and requirements, but with a good billing and coding department, participating in a network of insurance providers can be a good investment for the practice.

Why Medical Necessity is Necessary

Why Medical Necessity is Necessary

Medical professionals must prove that that a particular service or treatment was necessary before a patient’s healthcare insurance provider will pay for it.

Medical necessity trumps other criteria in the adjudication process and Nitin Chhoda provides new insights into why proving medical necessity is necessary, particularly in the current healthcare climate.

medical necessityMedical Necessity
Medical necessity refers to steps taken to evaluate, diagnose and treat disease, illness and injury.

Procedures, and the reason for performing them, form the heart of the medical necessity clause.

Insurance companies won’t reimburse for anything that doesn’t fit the definition of medical necessity.

Preventative measures may be medically necessary, but that doesn’t mean they will be deemed necessary by an insurance provider. In an era of abbreviated healthcare insurance policies, some forms of preventative care may not be covered at all.

It’s All About the Money
Receiving a reimbursement denial interrupts revenue and requires valuable time to rectify or appeal. It’s an especially frustrating experience for practitioners, who often feel that they’re being second guessed by individuals with no practical knowledge of the patient in question.

For insurance companies, it’s all about the money. If medical professionals want to be paid, they must provide documentation to support their actions.

Insurance companies base their payment decisions on a set of parameters that utilize a generally accepted set of procedures. To ensure services remain within the medically necessary rule, practitioners should focus on performing an exam that’s relative to the client’s complaint and document elements of their history as it applies to the visit. If documentation falls short of the intended billing code, bill at a lower code.

ICD and CPT codes
Documentation of medical necessity is supported by ICD-9 and CPT codes. During the adjudication process, insurance companies refer to the ICD and CPT codes clinicians provide. They’re the nuts and bolts of a reimbursement claim. Inclusion of coding that supports findings and actions at the time of the patient’s visit are essential for facilitating the payment process.

Practitioners should be aware that certain codes in medical billing convey a wealth of information in clusters. Many of these are used frequently and in conjunction with specific problems that occur together.

medical necessitiesIt’s important to learn which of those codes are used together most often and ensure multiple patient issues are reflected in the coding choices.

Clinicians often see the medical necessity clause as a tool to withhold or ration services to patients and payments to providers.

Insurance companies view it as a way to save money, ensure they’re not paying for superfluous services, and not padding the pocketbook of practitioners.

The medical necessity clause serves as a check and balance system. To get paid, it’s up to clinicians to provide proper ICD and CPT codes that offer documented proof that the services they provided meet the definition of medical necessity.

Payer : Who Is It and Who Has the Money? Part 1

Payer : Who Is It and Who Has the Money? Part 1

Medical professionals collect reimbursement payments from a variety of sources. Known as payers, they encompass commercial insurance companies, third-party administrators and government-funded programs.

In part 1 of this revealing article, Nitin Chhoda identifies the major commercial payers and third-party administrators, and what clinicians need to know to obtain reimbursements.

payerA wealth of commercial insurance plans payer exists to help individuals pay for medical expenses. That includes preferred provider, point of service, health maintenance, and discount plans.

To ensure that services are paid for, practitioners must verify the client’s coverage each time they visit the office and ascertain any limitations as it will have a direct bearing on treatment options.

When contracting with a payer, it’s important for clinicians to know if the insurance company is the entity that actually sets the amount that medical professionals are reimbursed. Some participate in a payer network that determines how much practitioners are reimbursed for their services. Some networks pay better than others and clinicians should exercise due diligence in researching payers.

Commercial insurers
The most common form of insurance practitioners will encounter is the commercial policy, typically offered through the patient’s or spouse’s employer. This type of coverage will fall under one of the following:

•    PPO – A preferred provider network is a group of healthcare professionals and facilities that have agreed to provide services at reduced rates.
•    HMO – Health maintenance organizations rely on a network of healthcare providers, but clients are assigned a primary care physician and care must be accessed through that physician.
•    POS – Point of service coverage is a hybrid blend of a PPO and HMO payer. Patients who visit an HMO medical provider are covered under HMO benefits. If they see a PPO provider, they receive coverage through the PPO.

•    EPO – An exclusive payer or provider organization plan requires patients to select a primary care physician and obtain a referral before seeing a specialist.
•    High deductible plans – These offer patients low monthly premiums and deductibles that can begin at $4,000 or more.
•    Discount plans – These plans require patients to pay a monthly fee to obtain access to participating providers. They’re not true healthcare insurance plans.
•    COBRA – Coverage under a Consolidated Omnibus Budget Reconciliation Act plan is a payer that is dependent upon patients making their monthly payments on time. If a payment is late, claims will be rejected or the coverage cancelled.

A COBRA plan is interim coverage when an employee loses or leaves their job.

Third-party administrators
A third party administrator (TPA) or payer is the middleman of healthcare. TPAs are operated as an independent network, or price claims by accessing other networks.

They handle claims for employers who insure their own employees rather than participating in a commercial group program. medical payer

Reimbursement problems can arise for clinicians if the TPA prices the claim incorrectly or the claim isn’t paid according to the individual TPA agreement.

Before contracting with a payer, it’s essential for practitioners to determine which entity sets the cost of services and what those payments will be to the practice.

Different networks and commercial insurers for medical billing have their own set of rates and reimbursement requirements that must be met for clinicians to be paid and practitioners must conduct sufficient research to ensure they’ll be reimbursed appropriately.

Medical Billing — Its Role and What it Means to Your Office Structure

Medical Billing — Its Role and What it Means to Your Office Structure

A structured medical practice is essential to ensure that reimbursement claims are submitted in a timely manner.

Missing, lost, misplaced or improperly filed patient records creates unnecessary medical billing delays and interrupts the flow of funds into the practice.

billingOrganization is the key to a well-run practice that treats as many patients as possible and generates a steady stream of reimbursement claims for medical billing and coding specialists to process.

In the absence of clear cut rules, direction and procedures, waste and chaos results. Distracted billers can make costly mistakes.

Filing practices
Maintaining accurate and easy to access patient records is essential if a biller is to do his/her job. The information contained within the patient’s record is the basis upon which reimbursement claims are filed.

Incomplete, inaccurate or illegible records cause delays in medical billing and can easily result in a payment denial or rejection. The information needed to obtain payment must be maintained in a manner that allows billers to quickly access the information they need to submit claims.

Each to his own task
In smaller practices, staff members may be required to wear a variety of hats, including the clinic’s medical billing and coding specialist. While it’s possible for a clinic’s healthcare staff to multi-task by answering phones, looking up records, scheduling appointments and communicating with other healthcare facilities and pharmacies, it’s not conducive to medical billing practices.

Each team member should have set responsibilities and clear cut job descriptions to avoid wasted effort. That’s not to say that personnel shouldn’t be cross trained to handle other duties should the need arise. Clinicians need to plan for such contingencies and ensure staff has a clear understanding of what to do in specific circumstances.

Set office hours
Setting regular office hours allows patients to know exactly when the clinician is available and keeps practitioners from being pulled in too many directions at once. Scheduling appointments to see clients allows providers to best utilize their time and provides medical billing specialists with a steady stream of claims to submit throughout the day.

Some healthcare professionals prefer the walk-in method of seeing clients with no appointment necessary.

It eliminates the problems of cancellations and no-shows, but there’s no way to ascertain how many patients may or may not arrive.billing and documentation

Clinicians could find their medical billing specialists have few reimbursements to submit.

A well-structured office is one that operates efficiently and where every detail of a patient’s visit is carefully documented and filed for retrieval by the practice’s medical billing specialist.

Careful organization and an eye for detail ensures that billers have the information needed to process reimbursement claims to maintain a steady cash flow into the clinic.