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Navigating Autism Coverage and Billing: Insights and Best Practices

Join the Thom Biller User Group meeting on October 28, 2013, for an informative session led by Peter Woodbury. The agenda includes discussions on autism coverage complexities, demonstrations of SSP spreadsheet entries, and techniques for effective billing. Participants will engage in group activities to generate questions and suggestions related to autism service codes. Learn about simple to complicated cases, payer interactions, and billing strategies using real-world examples. This collaborative environment encourages questions and discussion to enhance understanding and application of autism service billing.

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Navigating Autism Coverage and Billing: Insights and Best Practices

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Presentation Transcript

  1. Thom Biller User Group October 28, 2013

  2. Program • Welcome from Peter Woodbury, • Group Activity – Questions and Suggestions • Break • 3 Types of Autism Coverage • SSP Spreadsheet Entry Demo • Questions and Discussion • Lunch

  3. Group Activity • Generate 3 questions on blue cards • Generate 3 suggestions on red cards

  4. 3 Levels of Complexity • Simple: (ex: MED) • Single autism service code and rate • Single payer • Moderate: (ex: HPO) • Single autism service code and rate • Two “payers” (one primary and one subcontracted for autism coverage) • Very: (ex: BCB) • Multiple service codes and rates • Single payer • Contractual adjustments with DPH

  5. Simple Cases • Single autism service code and rate • Single payer • May or may not require PA • Special cases • Parent present • Examples • Straight MED

  6. Simple Rate File Example: MED

  7. Simple Autism Client Setup • Single Coverage (MED) • MED coverage needs authorization record in Thom Biller, but may or may not need PCC

  8. Simple Autism Client Demo

  9. Moderately Complicated Case • Examples • MCO with MED Secondary • Third-party insurer with behavioral health subcontractor for autism service (e.g., Harvard Pilgrim + United Behavioral Health) • Primary payer rate file must not have autism service codes • Secondary payer rate file must have autism service codes

  10. MCO Rate File Exampleno autism services So autism services drop down to the MED secondary that does have autism rate codes.

  11. MCO with MED Secondary Client Demo

  12. Third Party Rate Filewhen behavioral health arm handles autism claims No autism services in rate file. Autism services will be picked up by the secondary behavioral health payer (such as UBH)

  13. Behavioral Health Provider Rate Filefor autism services No EI services codes. Only autism services.

  14. Third Party with Behavioral HealthSecondary: Client Demo

  15. Complicated: Blue Cross High and low rates. Overbill for low rate services so balance can be transferred to DPH. “Low rate supervision” is really a direct service H2019 to Blue Cross; it is only “supervision” to DPH.

  16. Blue Cross Client Demo

  17. SSP Spreadsheet Load • Open spreadsheet in Excel • “Save As” CSV • Load CSV into Thom Biller • Pre-screening report warns of problems • Cancel if you need to fix problems or return spreadsheet • Proceed to load • Each spreadsheet record is used to pre-fill an event record in Thom Biller

  18. Spreadsheet Demo

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