Playing the Game

Most patient’s benefits start over at the beginning of the year. A small handful have a “benefit” year which is something other than a calendar year, typically July to June.  For those that have the majority calendar year policies, this means deductibles will re-start in the new year (if you submit a claim in 2012 for dates of service in 2011, they still process with 2011 and will not go towards the 2012 deductible).  Since many of you don’t deal with the details of insurance often, I will give you some reminders of what happens in the new year.  First, all patient’s insurance benefits should be re-verified at the beginning of each year.  In my offices, we get “update” forms just to re-verify addresses, phone #, etc. and get a NEW copy of insurance cards.  Many people will tell you none of this has changed, maybe that’s true, but for those you catch who moved, etc. and have completely new information, you will be glad you went to the trouble.  It’s prudent to always get new insurance cards since sometimes subtle changes occur to policies; higher deductibles, ID number changes, etc.  When you call to verify insurance, make sure to use a form.  We have one on the website for you to use as a template (Health Insurance Verification Form).  It’s important to get all questions answered and if you simply jot down the info they tell you, as they ramble it, you may miss out on some important details.

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As we approach the end of the year, there are a few things to keep in mind with regards to patient’s health insurance.
1) For many people, their deductibles may actually, finally, be met! This means they should use their benefits as much as possible while their responsibility is much less before the new year and when most people’s deductibles start over.
2) Double check where patients are in their benefits. Towards the end of the year, they may be close to maxing out their benefits. Knowing how many visits a patient has left under insurance can help avoid costly patient balances.

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I don’t know about you, but I have horrible luck getting COBRA to pay claims the first time.  For some reason, when this special, expensive coverage is supposed to kick in, it doesn’t – time and time again.  Patients always say they’ve got COBRA and there should be coverage, but the denials flow in.  Sometimes, it takes numerous phone calls before things get sorted out.  It’s the most bizarre thing.  If a patient has COBRA, just keep trying to submit your claims, EVENTUALLY they should get paid.  This is definitely a case where it helps to have the patient call and follow-up too….Considering how expensive it is, you’d think they’d treat these people and their coverage like royalty, instead, it’s like they’re at the bottom of the food chain.  Very odd.

Nowadays you need to use more and more objective findings to document a patient’s improvement and response to treatment. A major tool to substantiate a patient’s need for care are objective measurement tools such as Oswestry disability indexes, pain questionnaires, etc.  The inherent problem with these assessments is that patient’s do not recall what they previously said and consequently report (verbally) feeling so much better but SCORING much worse on subsequent assessments.  Then there are those who think reporting that they are worse will result in MORE authorized treatment when, in fact, the opposite is actually true.

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DESCRIPTION: All the basics and all the details you need to make a living billing your patients’ insurance successfully.  In this book, you will find information such as:

• How to decide whether to bill insurance or not in your practice
• Detailed directions on how to work with over 15 major insurance companies or conglomerates
• Samples of more than 25 forms that you may need to use in varying situations, along with complete instructions for their use
• Details of how and when to use each type of code and which codes NOT to use!
• Access to an acupuncture-specific insurance website for downloading forms, getting industry updates, and much more!
• Best practices for planning your patients’ care when insurance will be billed
• How to actually submit and manage a claim whether you are billing private fee-for-service insurance companies, managed care, workers’ comp, or personal injury cases

I have been busy getting the forums up and running. We are planning to have two general forums. One is for discussion of individual insurance companies and the other for a discussion of laws, regulations, and issues from and about individual states. I have been concentrating on the states for now and have the Midwest and Northeast regions up and running. Stay tuned for the rest of the US regions and then I will start populating individual insurance companies…

Our goal is to build the most useful resource for acupuncturists billing insurance around. Please help us create this community.

The book is going to be released any day now. To purchase it (and get a pre-publication discount of 20%) click here.

I was pleasantly surprised last week when I had a patient sign an addendum to our PI Policy without complaining.  Although she had previously signed the more generic policy stating that, if she became responsible for her bill (if it wasn’t paid by an insurance company directly like it should be) she would have to pay the bill, it wasn’t specific enough.  I like to go into more depth about how the patient will most likely be paid directly (it seemed inevitable in this particular case) and if so, she will be required to pay our office within 5 days of receiving the check.  It also states that she understands that if she defaults on her bill, she will incur a penalty of 1.5%/month on the outstanding balance.

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So, here in California at least, all of the Practitioners have been receiving “Cigna election to participate request forms’ to sign and send back to ASH…to reiterate their desire to be a Cigna provider.  Hopefully this will bi-pass any weird Cigna thing that I had previously written about happening.  If you haven’t signed yours and sent it back in yet and want to be a Cigna provider, you must do so immediately.

ASH just posted a reiteration of how the whole Kaiser arrangement works, I would like to recap it here for you since it is important if you see Kaiser patients via ASH.

1) The current referral situation is this:  Kaiser generates a referral for acupuncture.  This referral is good for 1 year.  The patient must have a referral on file while using their ASH benefits. When it ends, they should go back to Kaiser.

2) From this initial referral, the patient has 5 visits (like the threshold many pracitioners have) that they get which do NOT require authorization.

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