Out of Network Billing Tips

out of network billing tips

 

Here are some tips to ease out of network billing confusion:

What/Who is Out Of Network?

  • Clinicians who have not signed a contract with an insurance company and do not have to abide by a contracted rate.
  • Can still be subject to insurance audits for medical necessity and are still considered a HIPAA-covered entity.
  • Some plans may not have out of network benefits at all.
  • Never guarantee a client that they will get reimbursed for seeing you out of network.
    • Usually, OON has very high deductibles which means the client (or you) would not get reimbursed until the deductible is met.

Options with OON billing:

  • Charge client your full fee and give them a superbill to submit to their insurance company (Recommended!)
  • Submit OON billing for them, do not accept assignment (payment), and have the insurance company reimburse the client
    • Depending on the client’s OON benefits
    • Check ‘No’ in Box 27
  • Submit OON billing for them and accept assignment, charge client the difference between what insurance reimburses you and your full fee (balance billing)
    • Or go off of what the OON benefits are and do not balance bill—your choice

Superbill

  • Itemized bill given to clients to submit to their insurance company for payment
  • Can only do this if you are OON
  • Has the same information that is on a claim form including:
    • Client’s demographic information
      • Insurance information, date of birth, address
    • Your EIN/NPI/License Number
    • The client’s diagnosis
    • CPT code and description
    • What you are charging insurance and what the client paid you

Usual Customary and Reasonable Rate

  • Think of it like an unofficial out of network rate (without a contract)
  • Established to protect insurance companies from paying at the mercy of whatever providers charged
  • Insurance companies take an average of each CPT code billed by providers with the same licensure level in your region to determine UCR
    • This is why you should bill your full fee to insurance companies.
  • Works like a contracted rate, but you can balance bill
  • Example A:
    • Client has an OON deductible of $2,000 and the UCR is $100
    • You bill the client and the insurance company $150
    • The insurance company only applies $100 towards the deductible, but you can charge the client higher than the UCR due to not being in-network.
      • This is called ‘balance billing’ and is acceptable to do due to being OON and not having a contract with the insurance company. This is a contract violation if in-network as you have to collect your contracted rate and cannot balance bill.
  • Example B:
    • Client has met their OON deductible and insurance is paying 80% co-insurance, UCR is $100
    • You bill the client and give the client a superbill with a $150 charge on it
    • The insurance company reimburses the client $80 (based off of the UCR and not what you billed the client).

 

oon billing options

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6 Tips to Get Through a Care Review With an Insurance Company

 

You go to check your voicemail after a long day of seeing clients and you hear the message you’ve been dreading. It’s a representative from an insurance company wanting to do a care review on one of your clients and they’ve asked you to call them back. AHHHHH—but wait!

Don’t panic.

You’ll be just fine.

I’ve had many of these phone calls throughout the years and every time the person on the other end of the phone was pleasant/friendly and asked me basically the same questions.

Here are some tips to get you through it:

  • Have the client’s chart in front of you and skim over their intake note and treatment plan prior to calling the representative back.
    1. This may seem obvious, but reading over the intake note will help jog your memory of the client and why they came to see you in the first place.
  • Some things to make note of:
    1. The client’s diagnosis
    2. The date they started seeing you and what brought them into treatment
    3. Any prior history of treatment and/or hospitalizations or any since they have started treatment with you
    4. Substance abuse history
    5. Current supports (family/friends/significant other)
    6. Current psychosocial stressors
    7. Medications
    8. Current and past Suicidal/Homicidal Ideation/Attempts
  • Look up their diagnosis in the DSM.
    1. Even if you have been using DSM terminology in your notes, the care reviewer will want to see that the client has met medical necessity for the diagnosis. I’ve found it always helpful to give the DSM dx a once over so that it is fresh in my mind before making the call.
  • Be prepared to speak about their treatment goals and what approaches/interventions you have been using to reduce their symptoms.
    1. Evidence-based treatment interventions
  • Be prepared to give an estimated length of treatment and what your plan is moving forward.
  • Stick to the facts. Be concise and clear.

Remember that the care reviewer is almost always a clinician, just like you, and they are doing their job.

They are not trying to recoup money from you or catch you in some sort of act. They are checking in on the client’s progress. Often times they offer helpful tips or resources that are available to the client on the insurance company’s website.

Don’t put off calling them back—the phone call should take 15-20 minutes and if you delay calling them, it could pose problems for you with reimbursements. It will look bad—just call them back.

Once you give them some clinical on the client, they most likely won’t call you back regarding this client for another 6 months or so, but might after then to check-in on the client’s progress.

Repeat after me:

“The treatment I am doing is preventing a higher level of care. If the client were not receiving treatment from me, they may eventually have to be hospitalized.” This is the golden rule of care reviews.

I hope this helps ease some anxiety involved with care reviews!

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Insurance and Expanding into a Group Practice

Insurance and Expanding into a Group Practice

First of all—congratulations!

If you are reading this post, that means you are at least thinking about expanding your practice and forming a group, which hopefully means you have a successful group practice or maybe just big dreams!

For the sake of this blog post, I am going to assume that you are in a solo practice with a sole proprietor EIN and have individual contracts with insurance companies.

Here are the steps you should take when expanding from a solo practice to a group practice:

1. Prep work

  • Decide what type of business entity you want to form
    • LLC/PLLC, S-Corp etc.
    • This might include speaking with a lawyer or accountant on which business structure works best for you
  • Obtain an NPI 2
    • Can get one here (the same as your NPI 1).
    • This will be the NPI for your group/organization and is needed for billing.
  • Get a new business bank account for your new group practice/entity
  • Add your new group practice as a new practice location on CAQH and re-attest

2. Contact insurance companies:

  • This will most likely be your network representative or provider relations
  • Express that you are expanding to a group practice and would like a group contract.
    • Give them your sole prop EIN
  • Some insurance companies do not allow for group contracts unless you have a certain number of clinicians. In that case, you will just be changing your tax ID to your new LLC/S-Corp

Insurance and Expanding into a Group Practice

 

3. You will get sent group contracts and most likely group rosters.

  • List yourself as a clinician on the group rosters
  • Use your organizational NPI and your new group EIN
  • If you already have clinicians you are ready to credential, you would also add them to your roster.

4. While waiting for your new group contracts to be executed, you can still bill under your sole prop EIN as usual.

5. Once the contracts are executed, be mindful of the effective date.

  • Any date of service, on the effective date or after can be submitted under the new group EIN.

6. Sign up for electronic funds deposit/EFT using your new group practice bank account.

7. Billing as a group practice:

  • Essentially the same, except in Box 32a and 33a you are putting your NPI 2
  • In Box 33 you are checking ‘organization’ putting your group practice information.
  • You are also using your NEW group practice EIN in box 25

Employee’s NPI 1 in Box 24J

 

Type 2 NPI in Box 32a and 33a and Group Billing/EIN. Group name/billing address in box 33 and check Organization.

If the insurance company does not allow group contracts, you may have to continue to bill under your NPI 1 but with your group practice EIN.

 

Stay tuned for my next blog post about adding clinicians to your group practice contracts. 

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