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Private Payers/ Blue Cross & Blue Shield

Private Payers/ Blue Cross & Blue Shield. OT 232 Ch 9. Interpreting Compensation & Billing Guidelines. Contracts should state how allowed amounts are determined Usually a percentage of MPFS or a discounted fee-for-service arrangement 125% of MPFS Medicare pays $100, they allow $125

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Private Payers/ Blue Cross & Blue Shield

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  1. Private Payers/Blue Cross & Blue Shield OT 232 Ch 9 OT 232 Ch 9, #3

  2. Interpreting Compensation & Billing Guidelines • Contracts should state how allowed amounts are determined • Usually a percentage of MPFS or a discounted fee-for-service arrangement • 125% of MPFS • Medicare pays $100, they allow $125 • Compiling Billing Data • Practices usually bill at normal fee schedule and then adjust so they can keep track of how much is lost • Don’t send statement to patient until adjudicated OT 232 Ch 9, #3

  3. Interpreting Compensation & Billing Guidelines (cont’d.) • Getting Billing Information • Getting plans to ‘share’ info used to be more difficult • Largest private payers were sued for unfair business practices • Settlement resolutions, page 313 • Billing for No-Shows • Determined in contract and financial policy OT 232 Ch 9, #3

  4. Interpreting Compensation & Billing Guidelines (cont’d) • Collecting Copayments • They can vary • Flat amount vs. rate based on • Service provided • Procedure performed • Multiple visits in a day • Secondary’s copay? • Two methods • Copay is subtracted from fee • Fee is reduced by copay OT 232 Ch 9, #3

  5. Interpreting Compensation & Billing Guidelines (cont’d.) • Avoiding Silent PPOs • Provider & payer form a PPO contract, then the payer ‘leases’/shares contract info with a smaller payer so their members can take advantage of the discounted rates also. • Provider will get more patients • Illegal in some states, but not all, so look for wording in contract OT 232 Ch 9, #3

  6. Interpreting Compensation & Billing Guidelines (cont’d.) • Billing Surgical Procedures • Preauthorization/precertification required for elective surgery • Emergency surgeries usually approved within a specific time period • Utilization Review Organization (URO) • Service hired by a 3rd party payer to review major treatment plans submitted for preauthorization OT 232 Ch 9, #3

  7. Private Payer Billing Management & Claim Completion • Plan Summary Grid • Cheat sheet for provider for each payer dealt with • Lists specifics of contract • Major code bundles • Global periods • Coding guidelines • Documentation requirements OT 232 Ch 9, #4

  8. Private Payer Billing Management & Claim Completion (cont’d.) • Medical Billing Process • Steps 1 – 4? • Covered! • Step 5 – Review Coding Compliance • Double, triple check • Current? • Properly linked and documented? • Step 6 – Check Billing Compliance • Using plan summary grid, make sure everything’s correct for that particular payer • Step 7 – Prepare and Transmit Claims • 837 vs. 1500 • Communications with Payers OT 232 Ch 9, #4

  9. Capitation Management • Patient Eligibility • Monthly enrollment list is sent with payment every month • Important to always verify • Referral requirements • Required to stay in-network? • Encounter Reports and Claim Write-Offs • Simple form vs. regular report? • Charges for services are written off • Billing for Excluded Service • Refer to plan’s summary grid for instructions on handle billing for services not covered by the cap rate OT 232 Ch 9, #4

  10. Private Payer Billing Management & Claim Completion • Plan Summary Grid • Cheat sheet for provider for each payer dealt with • Lists specifics of contract • Major code bundles • Global periods • Coding guidelines • Documentation requirements OT 232 Ch 9, #4

  11. Private Payer Billing Management & Claim Completion (cont’d.) • Medical Billing Process • Steps 1 – 4? • Covered! • Step 5 – Review Coding Compliance • Double, triple check • Current? • Properly linked and documented? • Step 6 – Check Billing Compliance • Using plan summary grid, make sure everything’s correct for that particular payer • Step 7 – Prepare and Transmit Claims • 837 vs. 1500 • Communications with Payers OT 232 Ch 9, #4

  12. Capitation Management • Patient Eligibility • Monthly enrollment list is sent with payment every month • Important to always verify • Referral requirements • Required to stay in-network? • Encounter Reports and Claim Write-Offs • Simple form vs. regular report? • Charges for services are written off • Billing for Excluded Service • Refer to plan’s summary grid for instructions on handle billing for services not covered by the cap rate OT 232 Ch 9, #4

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