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Enrollments – Ask a Biller #1

This week, Dylan and Maggie covered contracting with insurance companies and the electronic claim and payment processing enrollments. You can see the entire webinar below. 

Episode 1:

See the full transcript here:

Dylan: 00:04 Hi everyone and welcome to the first installment of Ask a Biller webinar. We’re really excited to spend some time with you today talking about your questions for insurance and billing. My name is Dylan and I’m a Medical Billing Specialist for SmartBilling Pro at SimplePractice.

Maggie: 00:17 My name is Maggie. I’m an Insurance Specialist here at SimplePractice, and we’re both really excited to get this first broadcast underway. So, thank you to everyone that sent us questions. Due to the volume of participants we are only going to cover questions that were sent in ahead of time and pertain to today’s topic.

Dylan: 00:33 Which is contracting with insurance companies and the electronic claim and payment processing enrollments.

Maggie: 00:38 So, please feel free to submit your suggestions in the dialogue box of the go to webinar application, however if you have questions that are specific to your SimplePractice account then you’ll want to enroll in our insurance billing class, which is at three p.m. Pacific today. It’s also at 11 a.m. Pacific on Tuesdays.

Dylan: 00:58 And if you don’t hear your question addressed today don’t worry because we plan on covering a lot of ground. And I really wanted to let you know that we appreciate your feedback on what topics you’d like us to cover.

Maggie: 01:07 Awesome. Let’s get started.

Dylan: 01:09 Let’s look at our first question from Joyce in Ohio.

Maggie: 01:12 So, Joyce wants to know, “I am interested in learning how to do out-of-network billing.” So, let’s start off by identifying the differences between in-network and out-of0network billing and what those terms mean.

Dylan: 01:23 So, when you’re in-network you are contracted with that health plan. If you are still unclear what that means don’t worry because we’re going to be discussing contracting in a few minutes. If you’re in-network you are required to submit claims on the client’s behalf and you are obligated to accept the healths plan’s contracted raise, also known as allowed amounts. And you cannot bill the clients for the remaining balance.

Dylan: 01:43 The major benefit of being in-network is that you have access to a much larger pool of potential clients seeking treatment, allowing you the opportunity to grow your practice much more quickly.

Maggie: 01:52 And out-of-network, the benefit here is that you can charge your clients whatever you think is fair. So, this could be your full fee and you have a few different options of how you can approach this. So, Joyce your options are: One, you can submit claims on your client’s behalf for them to be reimbursed. This way you still provide a service to your clients who may feel confused or overwhelmed by handling their own claims. This is known as courtesy billing and we’ll go over that in a little more detail in the next slide. The next option is that you can furnish your clients with a Superbill that they can submit to their insurance for reimbursement, also known as an insurance reimbursement form. This method is the easiest for you, but again, may create some anxiety for clients who aren’t very experienced with dealing with insurance and wouldn’t know what to do when resolving a denied or redacted claim.

Maggie: 02:47 And then your third option, which is less common and varies plan to plan, you can submit claims out-of-network and the payer may reimburse you directly rather than your client, which means that you receive the money from the insurance, but you can charge your client the remaining balance in order to collect your full fee. This is called balance billing.

Maggie: 03:14 And moving on to our next question. Terry Washington asks “I’m not understanding why Group Health requires an additional form to allow me to direct bill out-of-network.

Dylan: 03:24 Alright. This is a great question that we get a lot and it is not just relevant to this specific payer. Often times payers, even when submitting claims out-of-network, require information from you in order to add you to their roster. This does not mean you’re being contracted with them. It simply means that they need to have your demographic information in their system in order to accept claims. The three most common pieces of information that they’re looking for are as follows.

Maggie: 03:47 So, the first is a letter of intent. This can be short and simple. It’s a letter using your office letterhead ideally, addressed to whom it may concern. And the objective of this letter is to announce your intent to file claims and it should include your office address and contact information as well as your NPI, TIN, and license number, which is your tax ID with an annual license number, and your preferred effective date, and this should be the first date of service that you have with this client. So, I suggest writing one of these letters and just keeping it on file as a template for use with other payers.

Maggie: 04:26 They also may ask for a copy of your license, which is your clinical license. I recommend scanning a copy of this and just sending it to your computer so you can easily send that off. And then more commonly they may require that you send them a W9. And, again, we recommend keeping a scanned copy of the completed W9 on file so that you can send those to payers right away.

Dylan: 04:50 And once you’ve submitted the required documentation you should receive a notice from the payer that you have been added to their roster. If you don’t hear back from them in four to eight weeks I’d say that it’s always a good idea to follow up with them rather than assume that the request has been processed.

Maggie: 05:03 And having said that, some payers simply require that you submit your first claim to them and they pull the required information directly from the claim form and add you to their roster. So, it really depends on the payer. And, as you all know, every payer is different. And it’s always best to contact them and ask them what information is required, if any at all, before rendering the service. If you already completed sessions with the client, again, ask them for the effective date to be set as the day that you first saw the client retroactively.

Dylan: 05:34 Alright. Now we’re gonna go over how to become an in-network provider. It’s also commonly referred to as paneling and this can be a lengthy process with a lot of paperwork and waiting. How to join a network information can be obtained by calling the payer or looking online for more information and forms to download. Panels fill up and close, so it’s a good idea to check to see if they are accepting new applicants or not. Even if they’re not, get your application ready anyways and be sure to check back with them periodically so that you are ready when the panel opens again.

Maggie: 06:02 So, once the panel is open the first step is credentialing. Once you’ve filled out all the registration forms and submitted all the required additional documentation the payer will begin reviewing your application. Be sure that you have filled it out completely and attached all the documents they request or else your application could be denied or significantly delayed. They will be confirming your license, validating your malpractice insurance, and looking over your education and training experience. The wheels can move very slowly here, so we recommend you be patient, but also diligent. Check in with them and see that they received everything they needed and confirm that your address or payer application is being processed. It never hurts to confirm and confirm and confirm again.

Maggie: 06:45 And then the next step is contracting. So, this is when you are actually entering an agreement with the payer. Once the contract is signed you will be able to accept clients under the corresponding health plan. And that is when you are obligated to accept their contracted rates and abide by their benefits.

Dylan: 07:04 And listen everyone. I can only imagine how exciting it must be to have already jumped through years of hoops to finally make it to private practice and I’m sure you’re anxious to get started right away, but we recommend that you get these enrollments, which can take six to eight weeks or more, completed and out of the way before you begin seeing clients.

Maggie: 07:21 Or at least before you begin marketing yourself as an insurance provider or that you accept insurance. So, the next step to getting your practice up and running is to tackle EDI, ERA, and EFT enrollments. And this is in an effort to fully automate your insurance process. These will be crucial if you are using an online practice management system and if you want to submit claims as quickly and as frequently as possible.

Dylan: 07:53 So, the first thing we’re gonna try to understand is EDI. EDI stands for Electronic Data Interchange. And it’s basically a pipeline between you, the clearinghouse, and the payer. Once processed you will be able to submit claims electronically, which greatly reduces your processing time and speeds up your reimbursements. I’d also like to note that not all payers require an EDI connection, but if your practice management system or clearinghouse prompt you to enroll you should begin the process as soon as possible.

Maggie: 08:18 So, we have another question that came from Tracy. Tracy asks “How do I get insurance payments to electronically deposit and automatically post to the client’s account?”

Dylan: 08:29 Well, first off what you’ll need is a practice management solution that already has these capabilities. Let’s assume that you do, then what we’ll need to do is complete an ERA enrollment for each payer so that you’re able to receive the electronic payments into your system.

Maggie: 08:43 What is an ERA, you may ask. An ERA stands for Electronics Remittance Advice. These are electronic versions of explanation of benefits or EOBs. And depending on your systems capability they can be auto-posted to your client’s account. This is a highly recommended feature to utilize as it’ll save you from hours of manually posting payments and drowning in paperwork. Again, the sooner these enrollments are completed the better as they will save you a lot of time in the long run. So, it’s worth noting that some payers will not allow for these connections depending on the practice management system and clearinghouse that you’re working with. So, you may still receive some paper explanation of benefits from payers. In this case you will need to sign up for the payer’s online provider portal and make sure to add that payment information to keep your accounts current.

Dylan: 09:37 And then getting ready for our next question I wanted to go over what EFT is. So, EFT stands for Electronic Funds Transfer and it’s a method of delivering insurance payments directly to your bank account via direct deposit. This is the fastest way to get paid, guys. In fact, being enrolled in EDI, ERA, and EFT is the best option for having a quick turnaround with processing of your claims. This is the way to keep the money flowing in.

Maggie: 10:02 And next we go to Kristen. Kristen asks “What would be the most convenient way to enroll into an ERA with the insurance companies, but still receive paper checks instead of direct deposit?”

Dylan: 10:15 Alright. This is a good question and an important distinction to make. EDI and ERA enrollments will generally be handled directly with your practice management system and/or clearinghouse, whereas EFT is a separate enrollment you will have to complete directly with the payer. It requires your banking and routing information. Sometimes EFT and ERA enrollments are combined with payers. So, check with them if you do not want EFT, but again, if you haven’t submitted your banking info an EFT connection isn’t even possible.

Maggie: 10:44 And finally from Jennifer.

Dylan: 10:46 “Since I get notified electronically when a check is sent and the info is added into SP I really need a way to log that I actually received the physical check.”

Maggie: 10:54 This is an important thing to touch on. In general, the ERAs will hit your practice management system more quickly than the funds hit your bank account. So, an EFT will usually process within a few days of receiving the ERA. And physical checks will take longer as they travel via mail. The best strategy for keeping track of your payments is to match the check numbers and the amounts that you’re seeing in your system to your bank account and constantly check that. If you receive an ERA and 14 days later you haven’t received the payment you’ll want to contact the payer and request that they re-issue the payment or find out what’s going on. If you’re not receiving ERAs you want to run the same comparison between your paper explanation of benefits and your bank account.

Maggie: 11:39 That about does it for our first episode of Ask a Biller. Thank you for those who summited questions and thank you to everyone who tuned in. We will be airing a new webinar every two weeks and we will be touching on many more areas of interesting confusion within the insurance billing realm. So, keep sending us your questions.

Dylan: 11:56 And next week, Thursday the 15th at 1:30 p.m. Pacific Standard time we’ll be hosting a very special webinar to discuss strategies for billing and getting paid with Telehealth. I really hope you join us.

Maggie: 12:07 See you next time! And until then, keep it simple.

Dylan: 12:07 Keep it simple.

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