Q: What should a provider look for in a billing company he/she might outsource their billing to?

A: There are four key elements that any provider should look for when searching for a partner to do their billing.

The first key element is to review the billing company's consistency in collections and turn around time. Ask for references.  Speak to the billing company's current and previous customers to find out if they receive consistent reimbursements for them.  Check with the references to see if they are getting paid in a timely manner.

The second key element to finding a billing company is exceptional customer service. As a provider, you want to make sure that the billing company is dedicated to your project, regardless of you how big or small your practice is. Ask questions about who will be your day to day contact, how many FTEs will be working your accounts, and when those people will be available for you to contact. Building a relationship with the representatives who will be working with your patients and their accounts is a great relief.  Knowing that your patients are receiving the same kind of care from these representatives that you would provide to them yourself is golden.

The third key element of finding a billing company goes hand in hand with the second element. All of the staff at the billing company should be educated on billing and collections.  They should always be up to par on the latest codes, rules, regulations and changes. When seeking a billing company, a provider should make sure to ask if the billing representatives are certified or trained in coding and billing, and what that entails. A billing company that has educated employees will be more than happy to share that information with you.

The final element of finding a billing company is to look for a company that has experience. A company that has been around for 5 years or more has had much more experience dealing with insurance carriers, patients and attorneys than a company that is just starting up. Always trust your instincts about the people you meet, and make sure to ask a billing company all of the questions that you have. If the billing company has experience under their belt, there should not be a question that is too hard or a project that they can’t help a provider with.

Information provided by Ranadene Tapio, President/CEO & Christy Kutzera, Director of Marketing, Medical Billing Professionals, LLC

Q: Can I charge no-show patients a fee for missed appointments?

A: You may be glad to know that Medicare has finally addressed what you must do in order to bill patients for "no shows."

Previously, each Part B office had their own requirements regarding charging Medicare patients for missed appointments. TRICARE (TriWest Healthcare
Alliance) regulations required providers to establish office practice policies regarding "no show" fees and required beneficiaries to sign an agreement taking financial responsibility for missed appointments. Other offices like WPS Medicare only required that provider also charge non-Medicare patients for no shows, too.

Fortunately, CMS now has an official written policy that applies to all carriers in all states, effective October 1, 2007. Under the MLN Matters Article MM5613, providers may bill patients for missed appointments; however, Medicare itself does not pay for missed appointments, so such charges should not be billed to Medicare.

Additionally, providers must not charge only Medicare beneficiaries for missed appointments; you must charge all of your patients, including non-Medicare patients. The amount must be the same for all patients.

You should make sure that your patients and staff is aware that they can be billed for a missed appointment and that Medicare should not be billed. Although it's no longer going to be required, you may still want to have your patients sign a form stating they are aware of the new office policy.

You can reference the article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5613.pdf

Information provided by Cyndee Weston, Executive Director, AMBA 

Q:  What is MultiPlan and why are they asking me to take a greater discount? 

A:   There are 3 products that MultiPlan offers.

 You can find a breakdown of the 3 products below that MultiPlan offers at http://www.multiplan.com/solutions/ 

     1)     Primary PPO Network--primary PPO network access under the PHCS Network and HealthEOS by MultiPlan (HealthEOS in Wisconsin only)

This is a PPO network in the true sense of the word.  If you are already a participating provider with PHCS, then according to MultiPlan customer service dep’t, you will need to recredential through MultiPlan. You may download the credentialing forms at: http://www.multiplan.com/providers/howtowork/credentialingforms.cfm      

If you are already credentialed with MultiPlan on the Primary PPO Network, your claims will be processed as an “in-network” participating provider at the contracted rate.  Patients will be responsible for the “in-network” copay or coinsurance and deductible.                                   

2)     Complementary Network-- The MultiPlan Network adds to the coverage of a primary PPO or HMO/POS/EPO by giving health plan participants an additional choice of providers at discounted rates. When participants seek care outside their primary network, they typically pay a higher coinsurance rate but share in the savings achieved by the network discount. In provider terms, this means that you will be accepting a discounted rate for your services but you will still be considered an “out-of-network”, non-participating provider. Your patients will still be responsible for the “out-of-network” copay, coinsurance, and deductibles which are typically higher than “in-network” on most plans.  

Example of how out of network claims would process if you are not a member of the Complimentary Network as opposed to being a member. Keep in mind that there are many, many, variables in insurance plans, but the following is a basic example:  

Non-Member—your billed charge for a visit is $100. The patient’s out-of-network deductible has been satisified. The patient has an out-of-network coinsurance of 30% (as opposed to an in-net copay of $15).  You will charge the patient $30 in the office for his coinsurance and submit the bill for $100.  The insurance carrier processes the claim at the out of network rate. You receive a check for $70 (the out of network reimbursement of 70%).  When all is said and done, you have received 100% of your usual and customary charges, or $100. 

Now, same scenario, but the patient’s out-of-network deductible has not been satisfied.  The patient must pay the entire $100 for services rendered and the entire $100 is applied to the patient deductible. Again, you have received 100% reimbursement for your usual and customary charge.  

Member of the Complimentary Network—your billed charge for the visit is $100.  You have agreed to accept a reduced rate of $65 for the visit.  The patient’s coinsurance amount is now $19.50 as opposed to $30.  A savings for the patient, but still more than his in-network copay of $15. You then submit your claim for $100.  The insurance carrier automatically reduces your bill to $65.  Now they pay you 70% of the reduced amount, or $45.50.  You have received a total of $65 for the visit.  

Now, same scenario, but the patient’s out-of-network deductible has not been satisfied.  The patient must pay the entire $65 towards his out-of-net deductible at the time of service.  You submit your claim for $100.  $65 is applied to the patient’s deductible.  You have received a total of $65 for the visit. However, because only $65 was applied to the out-of-net deductible, instead of the full $100, it will take the patient longer to satisfy that deductible. This may be a concern for providers who treat patients over the course of many visits.  

3)     Fee Negotiation—this is the 3^rd product that MultiPlan offers. MultiPlan

has negotiators working individually with non-contracted providers to reduce the cost of their claims.  Typically an offer will come to your clinic via fax requesting that you either accept or reject an offer to reduce your charges.  It is usually titled Expedited Fee Negotiation Agreement and requests that the provider accept the “expedited price”, less any out-of-network coinsurance and deductibles, for a specific patient visit.  It may also state that upon receipt of the signed agreement, your claim will be processed and payment issued within 10 days.  

Keep in mind that many of the larger carriers will process and pay a clean electronic claim in 14 days, therefore you may not actually get paid any faster than you would if you rejected the offer and stand by your usual and customary charges. 

According to MultiPlan’s customer service dep’t, a provider may enroll in the Primary PPO product for PHCS plans and exercise the option to not enroll in the Complimentary Network for plans in which he or she is out-of-network. Be sure to read all portions of the application to be certain that you are enrolling only in the products that you want.

Information provided by Cheri Freeman, CMRS, CRT Healthcare Management Systems
President Central Texas AMBA - http://www.localchapters.net/central_tx/index.html