One question we often get asked is “what is maximum out of pocket versus deductible?” Basically the are these two issues are opposite ends of the patient responsibility spectrum
Deductible is patient responsibility before anything is paid by the insurance company. As claims are submitted and processed, the insurance company identifies services which contractually have a deductible. The insurance company will tally or track how much of the deductible has been satisfied based upon the claims that have been submitted. Once the deductible has been reached, the insurance company will begin to issue payments for claims. Keep in mind deductibles are tallied based upon allowance not the amount charged by the provider.
Should the patient have a co-insurance or a co-payment, this amount will also be tracked by the insurance company as claims process. These amounts are all deducted from the allowable reimbursement for the services, and that net amount will be the payment issued to the provider.
Many contracts have a maximum out of pocket, often called a “stop loss” limit. This is the maximum limit that the patient would have to pay during a contract period. This amount generally is a summation of all deductible amounts, co-payment amounts, and co-insurance amounts. At this point the patient is no longer responsible for any out of pocket expenses, and the insurance company will pay the full allowance.
Unfortunately Out of Pocket Maximums have been largely eliminated or raised to unreasonable levels, but you will see them for some patients.
Posted in PRACTICE MANAGEMENT.
By admin
– January 16, 2010
Medicaid is government funded health insurance, generally for persons with low income. In certain circumstances, Medicaid is provided for patients with certain medical conditions regardless of family income such as developmental delays, autism, pregnancy, severe mental illness. In most cases, a patient’s eligibily must be verified or recertified on a routine basis to maintain eligibility.
When a patient is determined to be eligible for Medicaid, they are issued an identification card. In PA, this is often referred to as an Access Card. Within about 90 days, this patient must select a Medicaid HMO as their carrier. Some Medicaid HMO’s include Gateway, Unison, and UPMC 4 U. For behavioral health services, all Medicaid claims are processed through either Community Care Behavioral Health (CCBH) or Value Behavioral Health, depending upon the of residence.
In order to be paid by Mediciad, a provider must be credentialled and enrolled as a provider. Additionally, each service location covered by a provider must be independently enrolled.
Posted in MEDICAID.
By admin
– January 13, 2010
I have a a question. If I am a Highmark provider with a Highmark provider # and then get approved for Magellan, if a prospective client asks if I am “in-network for BCBS,” is the answer yes or no? I just lost a new client after telling them I am in-network for BCBS through Highmark, since I have this Highmark # and am being paid for another client with this insurance, but when the client called BCBS to verify, they said I am not in network. Is there another way to be in-network for BCBS?
Posted in BLUES, PRACTICE MANAGEMENT.
By TGlatthorn
– January 10, 2010
Due to some confusion with Windstream, MPMS has been assigned new toll free numbers. Our new toll free voice number is 866-362-2760. The new toll free fax number is 866-362-6961. The local numbers remain unchanged. Please update your records with this information.
Posted in Uncategorized.
By admin
– January 5, 2010
State Farm Insurance is now offering Electronic Funds Transfer (EFT) or direct deposit for PIP and medical claims. This service will have payments deposited into your bank account several days sooner than check payments sent via mail. They are also providing a website so that you can download and print EOB’s for review and for us to post to the patient accounts.
I suggest the use of EFT services. Not only do you receive routine payments faster, but it elminates delays in mailing associated with holidays and postal delays.
If you are interested in using this service, please contact Melissa and she will work with the State Farm representatives to get you set up. As always, let us know if you have any questions.
Posted in PRACTICE MANAGEMENT.
By admin
– January 5, 2010
CMS has announced that the Part B deductible for all Medicare recipients will be $155.00 in 2010.
Keep in mind that most Medicare Part B patients have a supplement, but very few supplements cover the annual deductible. And the deductible will be applied by Medicare as the claims are processed, not according to the date of service.
If you should have any questions, please feel free to ask. We are here to help.
Posted in MEDICARE, PRACTICE MANAGEMENT.
By admin
– January 5, 2010
We have had a recent influx of questions related to the billing of Massage Therapy Services.
Generally speaking, massage therapy services, procedure code 97124, is not a covered benefit for personal insurance. It is considered to be an elective services. However, some massage therapy services may be covered by automobile and worker’s compensation carriers.
Trigger Point Therapy, procedure code 97140, provided by a properly trained therapist maybe billable if supervised by a licensed chiropractor. In PA, a licensed Chiropractor can supervisor a non-licensed support staff members. The term “supervised” means that the licensed provider is in the facility and available to oversee the services being performed. However, inclusive in Highmark’s contractis a stipulation that Highmark will not cover any services provided by any non-licensed staff member. Since massage therapists are currently not licensed in PA, you cannot bill for any services rendered by a massage therapist or by a chiropractic assistant.
So, all of this seems a bit confusing, right. It is. And it is an issue that is highly targeted during insurance post payment reviews. Our best recommendation is that any massage therapy services provided in your office should be provided independent of your practice. The massage therapist should be a tenant, and not an employee of your practice. Massage therapy services for commercial insurance patients should be a cash service, and not billed to commercial insurance. If services are rendered to a auto or worker’s compensation patient, we suggest that they be documented and billed by the massage therapist. Not all auto and worker’s comp carriers will pay a for massage services, so we recommend that you contact the adjuster to verify if the services will be covered before they are rendered.
Posted in CODING AND DOCUMENTATION, PRACTICE MANAGEMENT.
By admin
– December 13, 2009
Medicaid is insurance coverage provided to patients, primarily based upon income. Medicaid is also provide to patients based upon some conditions regardless of income; such as developmental delays, autism, several mental illness. and pregnancy. A patient must routinely be re-certified to maintain their eligibility for coverage.
When a patient is first enrolled in Medicaid, they are issued a state ID card, or Access card. Within about 90 days, the patient must enroll in a Medicaid HMO who will administer their claims and coverage. Common Mediciad HMO’s include Gateway, Unision, and UPMC 4 U. All behavioral health Medicaid services are processed through Community Care Behavioral Health (CCBH) or Value Behavioral Health.
For providers, they must be credentialed through the state e-Promise program to be eligible to provide services to a Medicaid recipient. This gives them the ability to bill and be paid by Access. The provider must also then be enrolled in the appropriate Medicaid HMO’s in order to bill and be paid by that organization. Medicaid is a state program and is not a managed care network. All providers who meet the eligibility criteria are able to be enrolled in Medicaid. The Medicaid HMO’s are managed care organizations and they often limit the number of providers that they will credential based upon population density in a county. There is no requirement for any HMO to allow a provider access to their network.
Each Medicaid HMO has different authorization requirements and benefits for their patients. Once a provider is enrolled with a Medicaid HMO it is important that they understand their contractual requirements for authorizations and timely filing. Additionally each Medicaid HMO has a different fee schedule. This information is also provided with the provider’s credentialing contract.
There are some very important things to keep in mind when billing for Medicaid, whether it is the Access plan or a Medicaid HMO:
- Medicaid is always the payor of last resort. This means that all claims must be submitted to personal insurance carriers before it is submitted to Medicaid. If a provider is out of network with a patient’s personal insurances, the claims must still be submitted to obtain a denial;
- If the patient has personal coverage, the Explanation of Benefits from that carrier must be submitted with the Medicaid claim;
- Medicaid claims have a very narrow timely filing window, generally 90 days. If there is personal insurance, this timely filing window starts the day the primary insurance processes the claim (i.e., the date on the EOB);
- Medicaid will pay for services up to their allowance, less what was paid by any personal insurance. For example, if the allowance for Medicaid is $50.00 and primary insurance paid $60.00, there will be NO payment made by Medicaid. If the allowance for Medicaid is $50.00 and primary insurance paid $40.00, there will be a payment made by Medicaid of $10.00;
- In certain circumstances, if the provider does not participate with the patient’s Medicaid HMO, it may be possible to be paid by the state Medicaid plan. However, it is still necessary to bill any personal insurance and the Medicaid HMO and submit those denials for consideration;
- If you are a Medicaid provider, YOU CANNOT BALANCE BILL THE PATIENT. In the signing of your contract you have agreed to this, and there are no exceptions.
For the most part, Medicaid will not pay you enough to build a successful practice. But with many specialties and populations it is an important part of servicing your customer base.
Posted in MEDICAID.
By admin
– November 11, 2009
Today’s question: If services are denied from and IME or URO, can i then bill these charges to personal insurance?
Generally speaking — NO! If services are denied by the IME (Independent Medical Examinor) or URO (Utilization Review Organization) (or PRO – Peer Review Organization) as being not medically necessary, then we recommend that you not bill those charges to personal insurance. Primarily, because an “expert” reviewing body has determined that the services do not meet the definition of medical necessity. And this finding gives the presonal insurance a prime reason to request a repayment of any money you receive. Yes, you may get payment. But if the personal insurance conducts a post payment review, that money will be requested to be refunded. Moreover, those services will be built into the calculations for the total payment request, which will skew the total refund requested in the favor of the insurance company.
If the IME or URO deny charges as not being related to the accident (work comp or auto) then there is a possiblity that you may be able to bill personal insurance for the charges.
Generally speaking auto and work comp carries have a very narrow view of the injuries related to an accident. You must be very clear in your documentation to relate the treatment to both the mechanism of injury and injuries reported to the patient. If you are providing services that are not related to the accident, those services need to be billed to personal insurance, and not as part of the accident.
Keep in mind, that if a URO or IME review is requested, this often occurs after a prolonged care period. If you charges are denied as not related to the accident, and you bill to personal insurance they may deny the medical necessity of care based upon the length of care and the acute condition of the patient.
We suggest extreme care in billing these charges to personal insurance. Be sure that your documentation clearly delineates the care related to the accident and be sure that your documentation clearly shows medical necessity.
Posted in CODING AND DOCUMENTATION.
By admin
– November 10, 2009
For some insurance companies we are able to do electronic posting and we do not need your eobs. This currently applies to all Highmark providers. With your consent, we can add this capability for Medicare payments as well. As more insurance companies provide this capability we will take advantage of this process.
However, for most insurance companies we still need to receive your eobs. If you provide us with originals, we will gladly either return them to you after we review them, or we will gladly file and store them for you. Keep in mind that eob’s need to be retained for 7 years.
Why is it so important that you send us eobs? Several reasons:
- When we are able to review eobs, we are able to identify rejection issues and take the necessary action to correct any problems in a timely fashion and refile the claims are appropriate:
- Each month, we call on your unpaid claims. If the insurance company tells us there has been a payment, we then verify that the payment was received by you and the check properly cashed. This process takes a great deal of time that in some cases is very unnecessary;
- By eliminating unnecessary phone calls, we can not only better focus on real issues that are preventing or delaying your payment, but we an also keep our costs down.
We ask that all eobs be provided to us as they are received, with all eob’s provided to us within 2 weeks of receipt. Should you have any questions, please feel free to ask any MPMS team member.
Posted in MPMS NEWS.
By admin
– November 9, 2009
