At one time in America, there was no such thing as "health insurance." Patients negotiated directly with hospitals and doctors, and paid what they could, often on a sliding scale, according to ability. Eventually, health insurance entered the market, easing the burden of healthcare costs.
It didn't take long to realize the ordinary rules of supply and demand would not apply, if the insurance company, not the patient, was responsible for the bill. Copayments, deductibles, and coinsurance developed as a check against overutilization. If the patient had some "skin" in the game, this would provide some disincentive, though not absolute, but some hedge against over-use. This protective requirement, though necessary, is at times at odds with AMA Code of Ethics Opinion 8.03, which holds: "The primary objective of the medical profession is to render service to humanity; reward or financial gain is a subordinate consideration.
"In the current economy, as available dollars are becoming scarce, insurance carriers have begun checking up on the collection of copayments, deductibles, and coinsurance. With greater regularity, physicians and hospitals are receiving letters requesting proof, in perhaps five randomly selected cases, that the provider has collected, or sufficiently attempted to collect the portion of fees which is the patient's responsibility. This comes as a shock to many providers, who in keeping with Opinion 8.03, and the historical tradition of sliding scales, based upon ability to pay, have subordinated financial ability to pay in favor of the higher duty to care for the patient's need.
It is important to understand, however, forgiveness of copayments could land you in hot water. Therefore, doctors must understand the rules regarding waiver of copayments. AMA Opinion 6.12 addresses the ethical considerations:
Opinion 6.12 - Forgiveness or Waiver of Insurance Copayments
Under the terms of many health insurance policies or programs, patients are made more conscious of the cost of their medical care through copayments. By imposing copayments for office visits and other medical services, insurers hope to discourage unnecessary healthcare. In some cases, financial hardship may deter patients from seeking necessary care if they would be responsible for a copayment for the care. Physicians commonly forgive or waive copayments to facilitate patient access to needed medical care. When a copayment is a barrier to needed care because of financial hardship, physicians should forgive or waive the copayment.
A number of clinics have advertised their willingness to provide detailed medical evaluations and accept the insurer's payment but waive the copayment for all patients.
Physicians should be aware that forgiveness or waiver of copayments may violate the policies of some insurers, both public and private; other insurers may permit forgiveness or waiver if they are aware of the reasons for the forgiveness or waiver. Routine forgiveness or waiver of copayments may constitute fraud under state and federal law. Physicians should ensure that their policies on copayments are consistent with applicable law and with the requirements of their agreements with insurers.
Where the insurance contract requires a doctor to make reasonable attempts to collect the patient's portion, an open question surrounds the definition of "reasonable attempts to collect the debt." Historically, doctors could satisfy the requirement by sending at least three letters attempting to collect the debt. However, the Office of Inspector General (OIG) has taken the position that the routine waiver of copayments could constitute a criminal kickback in Medicare cases.
This has emboldened private insurers, who are relying upon this contractual provision as a basis for a post-payment recoupment audit. If a provider cannot demonstrate efforts to collect from the patient, the carrier may demand a refund for any benefits paid across a large patient population.
Providers should be aware of this new emphasis upon patient responsibility. My advice would be to proactively get ahead of the problem. Contact your insurance representative to find out what is expected of you and document the response. By all means, if you are a physician and you receive a letter from an insurance carrier requesting proof of attempts to collect, do not ignore it. A failure to cooperate could constitute grounds for termination of the contract with the payer.
Because this emphasis upon collection of copayments is a fairly recent phenomenon, even if you have been deficient in the past, you may be able to satisfy the carrier by demonstrating a corrective plan of action going forward.
Courtesy of Physicians Practice, By Martin Merritt http://www.physicianspractice.com/blog/forgiving-patient-copays-can-lead-unforgiving-consequences?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=17122013
Showing posts with label commercial insurance. Show all posts
Showing posts with label commercial insurance. Show all posts
Monday, January 13, 2014
Wednesday, October 23, 2013
The Evolution of Government Intrusion on the Medical Profession
By Martin Merritt from Physicians Practice
This week found me sitting alone in our law firm library, preparing to defend a physician before the Texas Medical Board. In an era of electronic research, both legal and medical, it is rare to find anyone, (other than me), in the library. I not only enjoy flipping through real pages; some of which were bound and placed on these shelves 70 years ago, I enjoy getting momentarily sidetracked from my original mission.
I picked up this habit as kid reading the World Book Encyclopedia. Regardless of what I might be looking for, I would always stop and absorb eight to ten articles, just to learn about some historical fact I didn’t know existed.
This week, flipping through historical reports of medical ethics cases, many dating to the 1950s, I began to see a clear picture of something I wasn’t expecting to find. Virtually every federal regulatory concern currently plaguing the modern practice of medicine also existed in some form in the 1950s.
Comparable to Medicare RAC and external audits; physicians were losing their practices for improper charting and documentation. However, these losses usually pertained to life-and death matters, such as the prescription of narcotics. “Off-label promotion,” similar to the fen-phen scandal, usually concerned mundane, unapproved uses of common household remedies.
For example, a physician in the 1950s lost his license for charging patients $49 each for a treatment to remove gallstones using olive oil. (The board found that the oil, mixed with stomach acid, actually produced “soap balls,” not gallstones, as the physician improperly claimed.)
“Bundling and unbundling” issues were also present sixty years ago when a physician was disciplined by the board for routinely including fee-for-services charges that were already billed to the patient as part of the hospital’s charges.
Time and again, modern coding, charting and regulatory issues “pop” from the pages of history. Some cases represent quaint precursors to FTC “advertising” regulations. These appear as ethics disputes over the size of the lettering appearing on a physician’s office window, to questions about the exact line between acceptable public service promotion and impermissible advertising.
Half a century ago, one party was notably absent from the dusty pages of medical ethics cases: the federal government. There is a reason for this. Until the post-Civil War period of reconstruction, no federal laws governed a person’s conduct in any way. Slowly, beginning with the regulation of racially motivated murder, and laws pertaining to civil rights violations, Title 42 of the United States Code (containing laws related to civil rights and health and human services), began to grow in size and scope.
Today, in addition to racial offenses (42 U.S.C. §1983); Stark Law (42 U.S.C. 1395nn); the Anti-kickback Statute, (42 USC § 1320a–7b); HIPAA (42 U.S.C. § 300gg); and the Medicare law (42 U.S.C. 1395) are located in the growing Title 42 of the United States Code.
Many fear, and rightly so, that as healthcare insurance exchanges offered at healthcare.gov become fully operational, the federal takeover of the practice of medicine will soon be complete.
In the not-too-distant future, the common law principle, “A physician and patient are free to contract for services in any way they see fit,” will seem just as quaintly anachronistic as limits on the size of lettering on a physician’s office window.
Courtesy of Physicians Practice http://www.physicianspractice.com/blog/evolution-government-intrusion-medical-profession?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=22102013
This week found me sitting alone in our law firm library, preparing to defend a physician before the Texas Medical Board. In an era of electronic research, both legal and medical, it is rare to find anyone, (other than me), in the library. I not only enjoy flipping through real pages; some of which were bound and placed on these shelves 70 years ago, I enjoy getting momentarily sidetracked from my original mission.
I picked up this habit as kid reading the World Book Encyclopedia. Regardless of what I might be looking for, I would always stop and absorb eight to ten articles, just to learn about some historical fact I didn’t know existed.
This week, flipping through historical reports of medical ethics cases, many dating to the 1950s, I began to see a clear picture of something I wasn’t expecting to find. Virtually every federal regulatory concern currently plaguing the modern practice of medicine also existed in some form in the 1950s.
Comparable to Medicare RAC and external audits; physicians were losing their practices for improper charting and documentation. However, these losses usually pertained to life-and death matters, such as the prescription of narcotics. “Off-label promotion,” similar to the fen-phen scandal, usually concerned mundane, unapproved uses of common household remedies.
For example, a physician in the 1950s lost his license for charging patients $49 each for a treatment to remove gallstones using olive oil. (The board found that the oil, mixed with stomach acid, actually produced “soap balls,” not gallstones, as the physician improperly claimed.)
“Bundling and unbundling” issues were also present sixty years ago when a physician was disciplined by the board for routinely including fee-for-services charges that were already billed to the patient as part of the hospital’s charges.
Time and again, modern coding, charting and regulatory issues “pop” from the pages of history. Some cases represent quaint precursors to FTC “advertising” regulations. These appear as ethics disputes over the size of the lettering appearing on a physician’s office window, to questions about the exact line between acceptable public service promotion and impermissible advertising.
Half a century ago, one party was notably absent from the dusty pages of medical ethics cases: the federal government. There is a reason for this. Until the post-Civil War period of reconstruction, no federal laws governed a person’s conduct in any way. Slowly, beginning with the regulation of racially motivated murder, and laws pertaining to civil rights violations, Title 42 of the United States Code (containing laws related to civil rights and health and human services), began to grow in size and scope.
Today, in addition to racial offenses (42 U.S.C. §1983); Stark Law (42 U.S.C. 1395nn); the Anti-kickback Statute, (42 USC § 1320a–7b); HIPAA (42 U.S.C. § 300gg); and the Medicare law (42 U.S.C. 1395) are located in the growing Title 42 of the United States Code.
Many fear, and rightly so, that as healthcare insurance exchanges offered at healthcare.gov become fully operational, the federal takeover of the practice of medicine will soon be complete.
In the not-too-distant future, the common law principle, “A physician and patient are free to contract for services in any way they see fit,” will seem just as quaintly anachronistic as limits on the size of lettering on a physician’s office window.
Courtesy of Physicians Practice http://www.physicianspractice.com/blog/evolution-government-intrusion-medical-profession?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=22102013
Thursday, October 3, 2013
Reduce Medical Practice Embezzlement Risk by Implementing Cash Controls
By Karen Zupko and Cheryl Toth Of Physicians Practice
Several years ago, we visited a practice in which the receptionist drove a Jaguar. We were particularly intrigued about this after we learned that her husband had been in and out of work for several years. As part of our engagement, we observed the receptionist checking in and checking out patients, and noticed fairly quickly that the encounter forms for several patients who paid in cash had "disappeared."
The next day, the receptionist called in sick and within a few days had resigned. In the end it became clear she had been tossing encounter tickets and pocketing cash for years. But because the practice didn't require anyone to account for all the day's encounter forms, nor balance money collected against what was posted to the computer system, no one was the wiser.
Front-desk embezzlement schemes are not uncommon and they are typically the result of loose protocols and lack of oversight. Reduce your financial risk by tightening cash controls using these proven practices.
1. Confirm that all encounter tickets for the day have been posted and "closed." At the end of each day, generate a "missing ticket" report from the practice management system and verify that all encounters have had charges and payments posted to them. This indicates the ticket has been closed. If your practice uses paper, ensure each ticket has a number. If your practice is paperless, the practice management system will generate and store an electronic tracking number. Tickets for patients who cancelled or did not show up for their appointment should be closed with a reason code for "cancelled" or "no-show."
Closing and accounting for all encounter tickets is the foundation of front-desk cash control, yet many practices skip this step. When we asked a neurosurgery group to generate a missing ticket report for the first time, it included more than 600 open tickets from the previous two years. Was someone in the practice on the take? Hard to say. But these days no one goes home from this practice until all tickets are located and closed.
2. Balance the ticket totals, posted payments, and actual money collected. This is standard operating procedure in any retail store or restaurant and should be your standard operating procedure too. Balance all three totals to the penny, and designate a manager or supervisor to review and sign off on the work. Thievery is thwarted when employees know someone is paying attention. For each day's balance, bundle the closed tickets (or equivalent electronic report) with credit card receipts, check copies, and the reconciled total payments collected and file them by day (electronically or on paper).
3. Lock it up. We were stunned to spot an unlocked strong box on the front desk of a small internal medicine group, from which staff and doctors regularly withdrew money for everything from the physicians' lunches to a box of copy paper. No lock, no protocol for who could withdraw money, and no paper trail of what was taken out. The timid manager simply put more money in when the balance was low. Be smart: Keep all money in a locked drawer (or overnight safe), and establish guidelines for who has access and what the money should be used for.
4. Separate the "change fund" from "petty cash." There is a difference. The change fund is an amount in small bills that's always the same — say, $200. This is the money staff use to make change for patients who pay in cash. Every day when they balance to the penny, the amount is counted out and kept in the drawer for change-making the next day.
The petty cash fund is a small account from which you borrow for small purchases. Each transaction is logged on a "chit," and ultimately posted as an expense in your bookkeeping system. When the petty cash fund is low, the manager replenishes it, and records this in the bookkeeping system too. If you don't track petty cash separately from change, you risk an easy-to-play financial shell game that never matches money spent with specific transactions. And it's difficult to spot missing money if there are no controls for reconciling transactions in the first place.
5. Randomly audit no-shows and cancelled appointments to make sure they are valid. In one surgical practice, we uncovered a front-desk staffer deleting appointments using the reason code "no-show" for patients who were seen and paid in cash. How did we catch it? An inordinate number of no-shows prompted us to pull charts. In several we found visit notes for patients who supposedly did not show up for their appointment — when they actually did. Not only had the practice lost the patient's payment, but because the staff person had made these encounters disappear, none of these services had been billed to insurance either.
6. Conduct background checks for EVERY employee who handles money. An attorney colleague is currently working on five cases that involve practice or billing service employees accused of stealing. Background checks should be an essential part of the hiring process. You'll be amazed at how many candidates are up to their ears in credit card debt, or who have been convicted of a crime. Both are clues that the candidate should not be hired to handle money.
Don't wait until after the hire to learn the facts. Companies such as Trusted Employees offer inexpensive background checks for employees of hospitals and physician offices, as well as other industries. (www.trustedemployees.com)
7. Pay attention to the personal situations of staff. A person who cannot pay their mortgage or has racked up thousands of dollars in credit card debt can feel desperate and act in ways they normally may not. Or, in the case of the Jaguar-driving receptionist, the luxury car should have been a signal to the manager and physicians that something was amiss.
Yes, we recognize that physicians and managers are busy. But when it comes to managing people who handle your money, there is no amount of busy that should get in the way of good old acuity and common sense.
Karen Zupko is President of KarenZupko & Associates, Inc., a firm that has helped physicians save time, save money, and reduce risk for more than 25 years.
Cheryl Toth is a KZA consultant and writer focused on technologies and process change that improve practice profitability and the patient experience.
Article courtesy of Physician's Practice: http://www.physicianspractice.com/embezzlement/reduce-medical-practice-embezzlement-risk-implementing-cash-controls?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=03102013
Several years ago, we visited a practice in which the receptionist drove a Jaguar. We were particularly intrigued about this after we learned that her husband had been in and out of work for several years. As part of our engagement, we observed the receptionist checking in and checking out patients, and noticed fairly quickly that the encounter forms for several patients who paid in cash had "disappeared."
The next day, the receptionist called in sick and within a few days had resigned. In the end it became clear she had been tossing encounter tickets and pocketing cash for years. But because the practice didn't require anyone to account for all the day's encounter forms, nor balance money collected against what was posted to the computer system, no one was the wiser.
Front-desk embezzlement schemes are not uncommon and they are typically the result of loose protocols and lack of oversight. Reduce your financial risk by tightening cash controls using these proven practices.
1. Confirm that all encounter tickets for the day have been posted and "closed." At the end of each day, generate a "missing ticket" report from the practice management system and verify that all encounters have had charges and payments posted to them. This indicates the ticket has been closed. If your practice uses paper, ensure each ticket has a number. If your practice is paperless, the practice management system will generate and store an electronic tracking number. Tickets for patients who cancelled or did not show up for their appointment should be closed with a reason code for "cancelled" or "no-show."
Closing and accounting for all encounter tickets is the foundation of front-desk cash control, yet many practices skip this step. When we asked a neurosurgery group to generate a missing ticket report for the first time, it included more than 600 open tickets from the previous two years. Was someone in the practice on the take? Hard to say. But these days no one goes home from this practice until all tickets are located and closed.
2. Balance the ticket totals, posted payments, and actual money collected. This is standard operating procedure in any retail store or restaurant and should be your standard operating procedure too. Balance all three totals to the penny, and designate a manager or supervisor to review and sign off on the work. Thievery is thwarted when employees know someone is paying attention. For each day's balance, bundle the closed tickets (or equivalent electronic report) with credit card receipts, check copies, and the reconciled total payments collected and file them by day (electronically or on paper).
3. Lock it up. We were stunned to spot an unlocked strong box on the front desk of a small internal medicine group, from which staff and doctors regularly withdrew money for everything from the physicians' lunches to a box of copy paper. No lock, no protocol for who could withdraw money, and no paper trail of what was taken out. The timid manager simply put more money in when the balance was low. Be smart: Keep all money in a locked drawer (or overnight safe), and establish guidelines for who has access and what the money should be used for.
4. Separate the "change fund" from "petty cash." There is a difference. The change fund is an amount in small bills that's always the same — say, $200. This is the money staff use to make change for patients who pay in cash. Every day when they balance to the penny, the amount is counted out and kept in the drawer for change-making the next day.
The petty cash fund is a small account from which you borrow for small purchases. Each transaction is logged on a "chit," and ultimately posted as an expense in your bookkeeping system. When the petty cash fund is low, the manager replenishes it, and records this in the bookkeeping system too. If you don't track petty cash separately from change, you risk an easy-to-play financial shell game that never matches money spent with specific transactions. And it's difficult to spot missing money if there are no controls for reconciling transactions in the first place.
5. Randomly audit no-shows and cancelled appointments to make sure they are valid. In one surgical practice, we uncovered a front-desk staffer deleting appointments using the reason code "no-show" for patients who were seen and paid in cash. How did we catch it? An inordinate number of no-shows prompted us to pull charts. In several we found visit notes for patients who supposedly did not show up for their appointment — when they actually did. Not only had the practice lost the patient's payment, but because the staff person had made these encounters disappear, none of these services had been billed to insurance either.
6. Conduct background checks for EVERY employee who handles money. An attorney colleague is currently working on five cases that involve practice or billing service employees accused of stealing. Background checks should be an essential part of the hiring process. You'll be amazed at how many candidates are up to their ears in credit card debt, or who have been convicted of a crime. Both are clues that the candidate should not be hired to handle money.
Don't wait until after the hire to learn the facts. Companies such as Trusted Employees offer inexpensive background checks for employees of hospitals and physician offices, as well as other industries. (www.trustedemployees.com)
7. Pay attention to the personal situations of staff. A person who cannot pay their mortgage or has racked up thousands of dollars in credit card debt can feel desperate and act in ways they normally may not. Or, in the case of the Jaguar-driving receptionist, the luxury car should have been a signal to the manager and physicians that something was amiss.
Yes, we recognize that physicians and managers are busy. But when it comes to managing people who handle your money, there is no amount of busy that should get in the way of good old acuity and common sense.
Karen Zupko is President of KarenZupko & Associates, Inc., a firm that has helped physicians save time, save money, and reduce risk for more than 25 years.
Cheryl Toth is a KZA consultant and writer focused on technologies and process change that improve practice profitability and the patient experience.
Article courtesy of Physician's Practice: http://www.physicianspractice.com/embezzlement/reduce-medical-practice-embezzlement-risk-implementing-cash-controls?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=03102013
Wednesday, October 2, 2013
Patient Out-of-Pocket Expenses Rise, Squeezing Physician Cash Flow
Maintaining cash flow is a growing challenge for physician practices now that their "bread and butter" privately insured patients are paying more and more of their healthcare expenses out of pocket, and it will get worse.
Out-of-pocket expenses not including premiums have increased to an average $768 for each privately insured consumer in 2012 according to the nonprofit, non-partisan Health Care Cost Institute, and are projected to skyrocket as much as 50 percent in 2015 under Obamacare’s numerous mandates.
Maintaining your practice’s cash flow requires much more than initiating more aggressive patient obligation collections policies. Payer contracting, practice marketing, and patient-service strategies must change to keep pace.
Payer Contracting
The market will soon be flooded with newly insured and reinsured through exchanges, mostly women because newly mandated coverage favors women and relies on men to share the cost. Employers will be re-evaluating policies and, if they keep insurance at all, will be gravitating to higher-deductible policies to keep pace with subsidized premiums.
Identifying major area employers with whom they insure, and whether or not they have high-deductible policies, is a new must. It isn’t just how much the insurer pays you anymore, it is how much the employee must pay you as well. Upscale employers typically have upscale insurance with higher reimbursements, lower co-pays and deductibles, and employees who can afford to pay them. As obvious as focusing on them as this may seem, going in-network with these payers and competing for their members has not dawned on most, if any, practices as a strategy.
Practice Marketing
Identifying and stratifying the best-insured employees and their families is a key competitive and marketing strategy. Getting those patients established with your practice is goal number one. Strategically, getting in network and understanding their needs is a must. Tactically, your marketing should be keyed to them. Your message should resonate with them. Your practice services should cater to their needs. And, you should be using experienced professionals for research, branding, messaging, and marketing.
Patient Services
Doing things right to gain a competitive advantage requires an investment in time and money. Keeping patients does not. It requires something else except in rare cases: a change in practice culture.
With all of the focus on patient-centered care, there is almost none on patient-centered services despite reams of literature showing that satisfied patients feel better, do better, and bring their friends and family along with them.
Change begins at the front desk with two very simple things: welcoming people and having an experienced staffer answer phones. How patients are treated sets the tone for the rest of the visit and determines the “patient experience,” and it all rests on office culture: Does your practice accept patients, or welcome them?
It all circles back to the beginning with two straightforward quirks of human nature: Happy patients are most likely to pay their bills while unhappy patients are most likely to sue.
For good advice on how to provide excellent customer service, click here.
Out-of-pocket expenses not including premiums have increased to an average $768 for each privately insured consumer in 2012 according to the nonprofit, non-partisan Health Care Cost Institute, and are projected to skyrocket as much as 50 percent in 2015 under Obamacare’s numerous mandates.
Maintaining your practice’s cash flow requires much more than initiating more aggressive patient obligation collections policies. Payer contracting, practice marketing, and patient-service strategies must change to keep pace.
Payer Contracting
The market will soon be flooded with newly insured and reinsured through exchanges, mostly women because newly mandated coverage favors women and relies on men to share the cost. Employers will be re-evaluating policies and, if they keep insurance at all, will be gravitating to higher-deductible policies to keep pace with subsidized premiums.
Identifying major area employers with whom they insure, and whether or not they have high-deductible policies, is a new must. It isn’t just how much the insurer pays you anymore, it is how much the employee must pay you as well. Upscale employers typically have upscale insurance with higher reimbursements, lower co-pays and deductibles, and employees who can afford to pay them. As obvious as focusing on them as this may seem, going in-network with these payers and competing for their members has not dawned on most, if any, practices as a strategy.
Practice Marketing
Identifying and stratifying the best-insured employees and their families is a key competitive and marketing strategy. Getting those patients established with your practice is goal number one. Strategically, getting in network and understanding their needs is a must. Tactically, your marketing should be keyed to them. Your message should resonate with them. Your practice services should cater to their needs. And, you should be using experienced professionals for research, branding, messaging, and marketing.
Patient Services
Doing things right to gain a competitive advantage requires an investment in time and money. Keeping patients does not. It requires something else except in rare cases: a change in practice culture.
With all of the focus on patient-centered care, there is almost none on patient-centered services despite reams of literature showing that satisfied patients feel better, do better, and bring their friends and family along with them.
Change begins at the front desk with two very simple things: welcoming people and having an experienced staffer answer phones. How patients are treated sets the tone for the rest of the visit and determines the “patient experience,” and it all rests on office culture: Does your practice accept patients, or welcome them?
It all circles back to the beginning with two straightforward quirks of human nature: Happy patients are most likely to pay their bills while unhappy patients are most likely to sue.
For good advice on how to provide excellent customer service, click here.
Tuesday, August 27, 2013
What to Do When Services are Not Paid by a Commercial Payer
If a practice is contracted as a participating provider with commercial insurers and networks, it must pay close attention to the patient "Hold Harmless" sections of the agreements. Many agreements prohibit billing the patient for services that are unpaid due to the insolvency of a payer (which may be the insurer or a self-funded employer), when the payer deems a service not medically necessary, for lack of compliance with utilization programs, or for failure to file a claim in a timely manner. Some agreements even go so far as to prohibit a practice from having a waiver signed by the patient in which the patient agrees to be responsible in these circumstances.
The best way to protect a practice so that it can bill the patient for services not paid for by the plan is twofold:
The best way to protect a practice so that it can bill the patient for services not paid for by the plan is twofold:
- Re-negotiate the language in agreements in the Member Hold Harmless provision, sometimes called "Billing the Patient," or the like, to more favorable language.
- Implement a patient financial responsibility statement / waiver* and signature process so that your patients acknowledge their responsibility to pay during these circumstances.
In re-negotiating the contract language, be sure the terms reflect that it is "only when required by applicable law" that you will not bill the patient / member under the circumstances that the plan is insolvent or has determined that the billed services are not medically necessary. In many states, practices are bound by such provisions by state regulations, but only with respect to state regulated HMOs and certain fully insured or government plans. These plans are generally required by law to retain reserves that will pay claims for a matter of months should the plans become financially unstable.
The majority of the members / patients that practices see under most agreements are in self-funded plans that operate under the federal Employee Retirement Income Security Act (ERISA). These plans do not have the same regulatory reserve requirements as the plans discussed above, and the contract should reflect that a patient waiver for such plans can be used to hold patients financially responsible if a self-funded plan does not pay for any service. The risk of a self-funded plan going belly up overnight and not having funds reserved to pay recent claims is therefore much greater. If a practice signs a network agreement that says that it can never bill the member for services not paid for by the self-funded plan, even in the case of insolvency or when the plan determines the service to be medically unnecessary, then billing the patient is technically prohibited even when there is a waiver signed by the patient agreeing to pay for claims in these cases.
The majority of the members / patients that practices see under most agreements are in self-funded plans that operate under the federal Employee Retirement Income Security Act (ERISA). These plans do not have the same regulatory reserve requirements as the plans discussed above, and the contract should reflect that a patient waiver for such plans can be used to hold patients financially responsible if a self-funded plan does not pay for any service. The risk of a self-funded plan going belly up overnight and not having funds reserved to pay recent claims is therefore much greater. If a practice signs a network agreement that says that it can never bill the member for services not paid for by the self-funded plan, even in the case of insolvency or when the plan determines the service to be medically unnecessary, then billing the patient is technically prohibited even when there is a waiver signed by the patient agreeing to pay for claims in these cases.
In revising your patient responsibility statement or waiver for patients covered under private payer plans, be sure to specifically include the patient's promise that he or she will be financially responsible, as allowed by applicable law, in the event that:
- His or her insurer or self-funded employer does not pay the claim in a timely and accurate manner
- The insurer or payer deems the service to be either not medically necessary or to be an excluded or non-covered service
- The payer or insurer denies the claim for lack of timely filing or adherence to utilization or payment policies
- A claim is prospectively or retroactively denied due to lack of eligibility or benefits
Although the practice is obliged to adhere to utilization management programs and payment policies in most agreements, many payers' programs and policies are not readily accessible, especially when leased networks are involved. The patient needs to be financially responsible and compliant with program requirements. When a multitude of claim administrators and employers are renting a network such as Multiplan, Galaxy, or Three Rivers Provider Network, each party leasing the network may have unique programs and policies that are not found on a central web site or portal. There can be some very good reasons to contract with leased networks, but these varying policies can make monitoring those who rent the networks more challenging. Sometimes these networks are less likely to modify the hold harmless language so as to appease all of their renting parties.
In addition to the hints provided above, when defining and administering the terms of the patient responsibility statement / waiver, the practice should be prepared to advise the patient in advance of denial, if it is aware that a service may not be covered. Provide the patient with the likely cost and payment terms that will be accepted, preferably in writing, including any prompt pay or hardship discounts that might apply. This type of communication can assist you in managing the patient's expectations and his or her commitment to timely payment. These extra steps can also add to the practice's compliance with the newly negotiated and more favorable hold harmless terms.
In addition to the hints provided above, when defining and administering the terms of the patient responsibility statement / waiver, the practice should be prepared to advise the patient in advance of denial, if it is aware that a service may not be covered. Provide the patient with the likely cost and payment terms that will be accepted, preferably in writing, including any prompt pay or hardship discounts that might apply. This type of communication can assist you in managing the patient's expectations and his or her commitment to timely payment. These extra steps can also add to the practice's compliance with the newly negotiated and more favorable hold harmless terms.
From the Jan/Feb issue of HBMA Billing by Penny Noyes http://www.hbma.org/news/public-news/n_what-to-do-when-services-are-not-paid-by-a-commercial-payer
Thursday, August 15, 2013
Complaints and Disputes Against Insurers
When an insurer or payer denies a claim unfairly or otherwise conducts business in an inappropriate manner, a physician practice can and should take action. Use the information on this page to better understand and navigate the complaint process.
Complaint proceduresPhysicians should first try to resolve the issue through the third-party payer’s internal complaint submission process. If you feel that your issue was not properly addressed in the internal process, consider seeking an impartial review by a state insurance regulatory agency, your state medical association or the AMA. Understand what to expect during the complaint process.
Filing a complaint against an insurer – mapTo assist you with the process of filing a complaint with the AMA, your state medical association or state insurance regulatory agency, the AMA has compiled the complaint process procedures for every state. Information is available through an easy-to-use interactive map.
Health plan complaint formUse the AMA Health Plan Complaint Form to let the AMA know about the hassles and unfair business practices you experience in your day-to-day interactions with health insurers.
File a HIPAA-related complaint
Physicians are encouraged to file a complaint with the AMA when an insurer is out of compliance with Health Insurance Portability and Accountability Act (HIPAA) transaction and code set standards. Also learn how to file a complaint with the Centers for Medicare and Medicaid Services (CMS) and the U.S. Department of Health and Human Services (HHS).
Courtesy of : AMA http://www.ama-assn.org/ama/pub/physician-resources/practice-management-center/health-insurer-payer-relations/complaints-disputes.page?
Complaint proceduresPhysicians should first try to resolve the issue through the third-party payer’s internal complaint submission process. If you feel that your issue was not properly addressed in the internal process, consider seeking an impartial review by a state insurance regulatory agency, your state medical association or the AMA. Understand what to expect during the complaint process.
Filing a complaint against an insurer – mapTo assist you with the process of filing a complaint with the AMA, your state medical association or state insurance regulatory agency, the AMA has compiled the complaint process procedures for every state. Information is available through an easy-to-use interactive map.
Health plan complaint formUse the AMA Health Plan Complaint Form to let the AMA know about the hassles and unfair business practices you experience in your day-to-day interactions with health insurers.
File a HIPAA-related complaint
Physicians are encouraged to file a complaint with the AMA when an insurer is out of compliance with Health Insurance Portability and Accountability Act (HIPAA) transaction and code set standards. Also learn how to file a complaint with the Centers for Medicare and Medicaid Services (CMS) and the U.S. Department of Health and Human Services (HHS).
Courtesy of : AMA http://www.ama-assn.org/ama/pub/physician-resources/practice-management-center/health-insurer-payer-relations/complaints-disputes.page?
Overpayment Recovery
Physician practices frequently have to deal with allegations that they have received overpayments from commercial and governmental payers. Attempting to determine the validity of alleged overpayments can divert significant time from direct patient care, which results in lost practice revenue. All too frequently, overpayment demands are made in the most general terms; the practice is not given the specific information—such as dates of service, patient names, or individual claims—which would enable the practice to determine independently the validity of the demand. Overpayment demands may also be intimidating, particularly when the amounts alleged are significant. Such amounts are frequently the result of "extrapolated" audits. Sizable demands may also reflect a payer’s contention that alleged overpayments have been occurring over many years.
The AMA has created "Questions to consider when addressing payer overpayment recovery requests on individual claims
" to help you handle overpayment recovery issues.
The AMA has created "Questions to consider when addressing payer overpayment recovery requests on individual claims
" to help you handle overpayment recovery issues.
Challenging overpayment allegations
Overpayment allegations can frequently be successfully challenged. Insurers may, for example, request overpayments of dubious legitimacy, hoping that the practice will simply concede. Although this may resolve a particular set of allegations, ready acquiescence may fix the practice as an "easy mark" to which an insurer may return with further demands. Informed opposition, even if not always entirely successful, may lead the practice to develop a better process for identifying overpayments,, as well as confirm for the insurer that the practice is not an "easy mark."
Federal and state regulations may help practices oppose or otherwise limit the effectiveness of overpayment demands. For example, a number of states limit the "look back" period over which insurers may claim overpayments. Many states also require insurers to provide specific information enabling physicians to determine independently the validity of demands prior to recoupment. The AMA has also successfully lobbied for significant limitations on the authority that certain government contractors (for instance, Medicare and Medicaid Recovery Audit Contractors) may exercise when pursing physician practices for alleged overpayments.
Read more about the AMA’s advocacy with respect to the Medicare and Medicaid Recovery Audit Contractor Programs.
Federal and state regulations may help practices oppose or otherwise limit the effectiveness of overpayment demands. For example, a number of states limit the "look back" period over which insurers may claim overpayments. Many states also require insurers to provide specific information enabling physicians to determine independently the validity of demands prior to recoupment. The AMA has also successfully lobbied for significant limitations on the authority that certain government contractors (for instance, Medicare and Medicaid Recovery Audit Contractors) may exercise when pursing physician practices for alleged overpayments.
Read more about the AMA’s advocacy with respect to the Medicare and Medicaid Recovery Audit Contractor Programs.
New Medicare overpayment obligations under the Patient Protection & Affordable Care Act
Wednesday, August 14, 2013
Proper Coding Can Help Prove Medical Necessity
For a service to be considered medically necessary, it must be reasonable and necessary to diagnosis or treat a patient’s medical condition. When submitting claims for payment, the diagnosis codes reported with the service tells the payer "why" a service was performed. The diagnosis reported helps support the medical necessity of the procedure.
For example, a patient presents to the office with chest pain and the physician orders an electrocardiogram (ECG). A 12-lead ECG performed in the office and interpreted by a physician is reported with CPT® code 93000. The reason the physician orders the ECG is because the patient is complaining of chest pain. The diagnosis code for unspecified chest pain is 786.59.
The provider must document the diagnosis for all procedures that are performed. The provider also must include the diagnosis for each diagnostic test ordered. A common error seen when reviewing medical documentation is that the provider will document a diagnosis and indicate tests ordered, but it is unclear that all the tests ordered are for the diagnosis documented in the assessment. For example, the patient presents with right knee pain and the physician performs an arthrocentesis. He also orders a chest X-ray. The only diagnosis documented is knee pain. The knee pain supports the medical necessity for performing the arthrocentesis, but it does not support the medical necessity for the chest X-ray.
In this case, the provider should be queried why the chest X-ray was ordered so the proper diagnosis can be reported. The provider may have wanted a knee X-ray and made a mistake when writing his orders. By asking the provider for clarification, you have prevented the performance of an unnecessary test because the provider really intended to order a knee X-ray. In this case, the knee pain would support the order of the knee X-ray. If the provider intended to order a chest X-ray, by asking for clarification you can report the service with a more appropriate ICD-9-CM code and eliminate a claim denial. In this example, the arthrocentesis is reported with procedure code 20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) and diagnosis code 719.46 Pain in joint; lower leg. The code for the X-ray is selected based on the anatomic site and number of views obtained.
Not all diagnoses for all procedures are considered medically necessary. Medicare and commercial payers have coverage policies that specify the diagnosis codes that support medical necessity for certain procedures. Also included in the coverage policies are documentation requirements. The documentation requirements can include diagnostic test values that must be met, that less invasive treatments be attempted before the service is determined to be medically necessary, or — for a repeat procedure — a statement of the outcome of the previous procedure of the same type. Knowing the coverage polices for the services provided in your office can help eliminate denied claims later.
The coverage policies are available for providers to review and adhere to when submitting claims. The coverage policies for Medicare are found at the Medicare Coverage Database. This database includes NCDs (National Coverage Determination), which are nationwide determinations for Medicare covered services; and LCDs (Local Coverage Determination), which are determinations if a service is covered carrier-wide by a MAC (Medicare Administrative Contractor). Using this database, you can search for coverage determination by CPT® or HCPCS Level II codes, and by your geographic region.
Private payers (e.g. Cigna, United Healthcare, etc.) have coverage policies as well. Most private payers have their coverage polices available on their website. Provider contracts with payers also include coverage policies. Review the coverage polices for the private payers you contract with, as well as Medicare if your provider participates in the Medicare program.
Word of caution: Do not alter the diagnosis code for a patient to match one of the diagnosis codes listed in the coverage policy as supporting medical necessity. The diagnosis code submitted must be supported by the medical record. It is inappropriate to report a diagnosis solely because it is on the approved list of diagnosis codes that meet medical necessity. Reporting a diagnosis that the patient does not have to receive payment for the service is fraud, which may result in fines and, in some cases, criminal prosecution.
When submitting claims, you must report the diagnosis that is indicated in the medical record for the procedures performed and ordered. Knowledge of coverage policies will help you to be proactive in avoiding claim denials and to educate your providers on the documentation required to support the services rendered. This is not to say that the provider should not perform the service if the circumstances may deem the service not medically necessary. If the physician determines the procedure is medically necessary even though the coverage policy does not approve it, this gives you the opportunity to educate your patients that the service may be denied by their insurance carrier. The patient then has the choice whether to have the procedure.
Article by Raemarie Jimenez, CPC - See more at: http://www.physicianspractice.com/blog/proper-coding-can-help-prove-medical-necessity#sthash.gaQDAPLq.dpuf
For example, a patient presents to the office with chest pain and the physician orders an electrocardiogram (ECG). A 12-lead ECG performed in the office and interpreted by a physician is reported with CPT® code 93000. The reason the physician orders the ECG is because the patient is complaining of chest pain. The diagnosis code for unspecified chest pain is 786.59.
The provider must document the diagnosis for all procedures that are performed. The provider also must include the diagnosis for each diagnostic test ordered. A common error seen when reviewing medical documentation is that the provider will document a diagnosis and indicate tests ordered, but it is unclear that all the tests ordered are for the diagnosis documented in the assessment. For example, the patient presents with right knee pain and the physician performs an arthrocentesis. He also orders a chest X-ray. The only diagnosis documented is knee pain. The knee pain supports the medical necessity for performing the arthrocentesis, but it does not support the medical necessity for the chest X-ray.
In this case, the provider should be queried why the chest X-ray was ordered so the proper diagnosis can be reported. The provider may have wanted a knee X-ray and made a mistake when writing his orders. By asking the provider for clarification, you have prevented the performance of an unnecessary test because the provider really intended to order a knee X-ray. In this case, the knee pain would support the order of the knee X-ray. If the provider intended to order a chest X-ray, by asking for clarification you can report the service with a more appropriate ICD-9-CM code and eliminate a claim denial. In this example, the arthrocentesis is reported with procedure code 20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) and diagnosis code 719.46 Pain in joint; lower leg. The code for the X-ray is selected based on the anatomic site and number of views obtained.
Not all diagnoses for all procedures are considered medically necessary. Medicare and commercial payers have coverage policies that specify the diagnosis codes that support medical necessity for certain procedures. Also included in the coverage policies are documentation requirements. The documentation requirements can include diagnostic test values that must be met, that less invasive treatments be attempted before the service is determined to be medically necessary, or — for a repeat procedure — a statement of the outcome of the previous procedure of the same type. Knowing the coverage polices for the services provided in your office can help eliminate denied claims later.
The coverage policies are available for providers to review and adhere to when submitting claims. The coverage policies for Medicare are found at the Medicare Coverage Database. This database includes NCDs (National Coverage Determination), which are nationwide determinations for Medicare covered services; and LCDs (Local Coverage Determination), which are determinations if a service is covered carrier-wide by a MAC (Medicare Administrative Contractor). Using this database, you can search for coverage determination by CPT® or HCPCS Level II codes, and by your geographic region.
Private payers (e.g. Cigna, United Healthcare, etc.) have coverage policies as well. Most private payers have their coverage polices available on their website. Provider contracts with payers also include coverage policies. Review the coverage polices for the private payers you contract with, as well as Medicare if your provider participates in the Medicare program.
Word of caution: Do not alter the diagnosis code for a patient to match one of the diagnosis codes listed in the coverage policy as supporting medical necessity. The diagnosis code submitted must be supported by the medical record. It is inappropriate to report a diagnosis solely because it is on the approved list of diagnosis codes that meet medical necessity. Reporting a diagnosis that the patient does not have to receive payment for the service is fraud, which may result in fines and, in some cases, criminal prosecution.
When submitting claims, you must report the diagnosis that is indicated in the medical record for the procedures performed and ordered. Knowledge of coverage policies will help you to be proactive in avoiding claim denials and to educate your providers on the documentation required to support the services rendered. This is not to say that the provider should not perform the service if the circumstances may deem the service not medically necessary. If the physician determines the procedure is medically necessary even though the coverage policy does not approve it, this gives you the opportunity to educate your patients that the service may be denied by their insurance carrier. The patient then has the choice whether to have the procedure.
Article by Raemarie Jimenez, CPC - See more at: http://www.physicianspractice.com/blog/proper-coding-can-help-prove-medical-necessity#sthash.gaQDAPLq.dpuf
Selecting the Right E&M Codes at Your Medical Practice
The focus on educating providers and coders on the selection of evaluation and management (E&M) services has increased over the years due to numerous factors, including: E&M codes make up the majority of procedures reported by physicians and mid-level providers; audits (e.g. OIG audit focus on E&M especially documentation using EHRs); and the fact that complexity of code selection can be confusing and ambiguous.
Most of the education focuses on the three key components (history, exam, and medical decision making). Proper documentation of these elements is extremely important but we cannot lose focus on the most important criteria for E&M code selection, which is medical necessity. Codes should not be solely selected based on the volume of the documentation of the three key components, but the nature of the patient’s presenting problem and medical intervention required by the provider.
As more and more physicians implement EHRs, there is an increase in the volume of documentation. EHRs are very useful tools if used appropriately, but can be abused to create pages of useless information that does not pertain to the date of service or the patient’s complaint for the encounter. We often see this with the review of systems and past, family, and social history components when elements from a previous encounter are carried forward. When you see the same information documented for the patient each time she is seen, it makes you wonder if the information is obtained each time or a system default. If it is obtained each time, is the information pertinent to the presenting problem?
An effective way to incorporate the focus on medical necessity of the service into your E&M training is to relate it to the provider’s typical patient. When a patient presents to the office, the provider can usually tell quickly how sick the patient is. The patient’s complaint for the day will dictate the questions the provider asks regarding the patient’s presenting problem. This information makes up the history component of the encounter.
Next, the provider examines the patient. The provider should exam all body areas and/or organ systems that are pertinent. Some providers may prefer to perform an eight-system exam for each patient but it might not be medically necessary. For example, a patient presents with an earache. An eight-system exam may not be warranted depending on the last time the patient was seen. If the patient was seen recently for a complete physical and is presenting for only an evaluation of the earache, the complete exam might not be necessary. However, if the patient has not been seen in over a year, the provider will take the opportunity to address the presenting problem(s) and perform a complete exam for preventive measures or conditions the patient may have. Sometimes a patient will present for one problem and “oh by the way” something else is also bothering them.
The medical decision making component includes the provider’s assessment, data collected (e.g. diagnostic tests), and treatment plan. Once the exam is complete, the provider will determine what tests are needed if any. When ordering tests, providers must document the reason for the test. If a definitive diagnosis has not been determined, the reason for the tests will be the patient’s signs and symptoms. Although differential diagnoses are not reported, they should be included in the documentation to support the severity of the patient’s condition.
If the patient is presenting with a headache and the provider is ruling out neurological conditions, it should be included in the documentation. The treatment plan should be documented. It can include medications prescribed, therapies ordered and/or procedures needed.
In addition to using the CMS documentation guidelines for E&M education, incorporate the nature of the presenting problems found in the CPT® E&M coding guidelines. Although the nature of the presenting problem is not one of the three key components, it helps the provider understand the types of conditions that qualify for the different levels of E&M. Focus your education on the patient’s condition, work needed to treat the patient, and the proper documentation to support the services rendered.
Article written By Raemarie Jimenez, CPC- See more at: http://www.physicianspractice.com/blog/selecting-right-em-codes-your-medical-practice#sthash.Z26Zg8gz.dpuf
Most of the education focuses on the three key components (history, exam, and medical decision making). Proper documentation of these elements is extremely important but we cannot lose focus on the most important criteria for E&M code selection, which is medical necessity. Codes should not be solely selected based on the volume of the documentation of the three key components, but the nature of the patient’s presenting problem and medical intervention required by the provider.
As more and more physicians implement EHRs, there is an increase in the volume of documentation. EHRs are very useful tools if used appropriately, but can be abused to create pages of useless information that does not pertain to the date of service or the patient’s complaint for the encounter. We often see this with the review of systems and past, family, and social history components when elements from a previous encounter are carried forward. When you see the same information documented for the patient each time she is seen, it makes you wonder if the information is obtained each time or a system default. If it is obtained each time, is the information pertinent to the presenting problem?
An effective way to incorporate the focus on medical necessity of the service into your E&M training is to relate it to the provider’s typical patient. When a patient presents to the office, the provider can usually tell quickly how sick the patient is. The patient’s complaint for the day will dictate the questions the provider asks regarding the patient’s presenting problem. This information makes up the history component of the encounter.
Next, the provider examines the patient. The provider should exam all body areas and/or organ systems that are pertinent. Some providers may prefer to perform an eight-system exam for each patient but it might not be medically necessary. For example, a patient presents with an earache. An eight-system exam may not be warranted depending on the last time the patient was seen. If the patient was seen recently for a complete physical and is presenting for only an evaluation of the earache, the complete exam might not be necessary. However, if the patient has not been seen in over a year, the provider will take the opportunity to address the presenting problem(s) and perform a complete exam for preventive measures or conditions the patient may have. Sometimes a patient will present for one problem and “oh by the way” something else is also bothering them.
The medical decision making component includes the provider’s assessment, data collected (e.g. diagnostic tests), and treatment plan. Once the exam is complete, the provider will determine what tests are needed if any. When ordering tests, providers must document the reason for the test. If a definitive diagnosis has not been determined, the reason for the tests will be the patient’s signs and symptoms. Although differential diagnoses are not reported, they should be included in the documentation to support the severity of the patient’s condition.
If the patient is presenting with a headache and the provider is ruling out neurological conditions, it should be included in the documentation. The treatment plan should be documented. It can include medications prescribed, therapies ordered and/or procedures needed.
In addition to using the CMS documentation guidelines for E&M education, incorporate the nature of the presenting problems found in the CPT® E&M coding guidelines. Although the nature of the presenting problem is not one of the three key components, it helps the provider understand the types of conditions that qualify for the different levels of E&M. Focus your education on the patient’s condition, work needed to treat the patient, and the proper documentation to support the services rendered.
Article written By Raemarie Jimenez, CPC- See more at: http://www.physicianspractice.com/blog/selecting-right-em-codes-your-medical-practice#sthash.Z26Zg8gz.dpuf
How to Code, Negotiate After-Hours Reimbursement at Your Practice
There are codes in the CPT® code book to report services a physician provides during "nontraditional" hours. If you prove that it’s in the payer’s best interest, third-party insurers may allow additional reimbursement for after-hours services.
Medicare and payers that strictly follow CMS guidelines will not pay additional reimbursement for after-hours services. However, you might succeed with private payers in negotiating payment for after-hours codes as part of a contractual agreement, especially if you use savings potential as leverage. Have your negotiator make it clear to the insurer’s representative that you’ll willingly send patients to the emergency department (ED) instead of offering in-office after-hours services, but that ED services can cost as much as 10 times more than comparable physician services.
To further demonstrate cost savings, you could also start billing all applicable after-hours codes for your practice. Over time, you will have compiled an archive of claimed charges, which you can use to show the insurer how often you provide these services. In this report to the insurer, consider adding data on the much higher price of ED visits for the same services.
Know the Codes
Based on the CPT®/AMA guidelines, you may report 99050 — Services provided in the office at time other than regularly scheduled office hours, or days when the office is closed (e.g., holidays Saturday or Sunday), in addition to basic service — for any service provided in the office at a time when the practice would normally be closed (e.g., weekends or evenings). Code 99050 is reported in addition to the code for the basic service.
If your practice already maintains regular hours on evenings, weekends, or holidays, and you provide a service during those times, you should skip 99050 and use 99051 — Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service.
If a 24-hour facility requests that your physician provide a redeye or early-bird service, AMA guidelines allow you to claim 99053 — Service(s) provided between 10:00 p.m. and 8:00 a.m. at 24-hour facility, in addition to basic service, in addition to the basic service. Code 99053 can be used whether the provider is already at the facility, or if the physician has to make a special trip to care for the patient. The code 99053 can only be used if the service provided occurs at a 24-hour facility, such as an ambulatory surgical center (POS 24), urgent care facility (POS 20), or emergency department (POS 23).
Emergency department physicians may report 99053 for services rendered between the hours of 10 p.m. and 8 a.m. The American College of Emergency Physicians fully supports this use of 99053, stating that this code is appropriate for late-night services, "especially given the nighttime practitioner availability costs typically incurred by all medical practices, including emergency medicine."
Article written by: By G. John Verhovshek, MA, CPC from: http://www.physicianspractice.com/blog/how-code-negotiate-after-hours-reimbursement-your-practice?utm_source=dlvr.it&utm_medium=twitter&mkt_tok=3RkMMJWWfF9wsRoluqXKZKXonjHpfsX57ugqXKS3lMI/0ER3fOvrPUfGjI4ETMNrI%2BSLDwEYGJlv6SgFSbXHMbl60bgMUhg%3D
Medicare and payers that strictly follow CMS guidelines will not pay additional reimbursement for after-hours services. However, you might succeed with private payers in negotiating payment for after-hours codes as part of a contractual agreement, especially if you use savings potential as leverage. Have your negotiator make it clear to the insurer’s representative that you’ll willingly send patients to the emergency department (ED) instead of offering in-office after-hours services, but that ED services can cost as much as 10 times more than comparable physician services.
To further demonstrate cost savings, you could also start billing all applicable after-hours codes for your practice. Over time, you will have compiled an archive of claimed charges, which you can use to show the insurer how often you provide these services. In this report to the insurer, consider adding data on the much higher price of ED visits for the same services.
Know the Codes
Based on the CPT®/AMA guidelines, you may report 99050 — Services provided in the office at time other than regularly scheduled office hours, or days when the office is closed (e.g., holidays Saturday or Sunday), in addition to basic service — for any service provided in the office at a time when the practice would normally be closed (e.g., weekends or evenings). Code 99050 is reported in addition to the code for the basic service.
If your practice already maintains regular hours on evenings, weekends, or holidays, and you provide a service during those times, you should skip 99050 and use 99051 — Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service.
If a 24-hour facility requests that your physician provide a redeye or early-bird service, AMA guidelines allow you to claim 99053 — Service(s) provided between 10:00 p.m. and 8:00 a.m. at 24-hour facility, in addition to basic service, in addition to the basic service. Code 99053 can be used whether the provider is already at the facility, or if the physician has to make a special trip to care for the patient. The code 99053 can only be used if the service provided occurs at a 24-hour facility, such as an ambulatory surgical center (POS 24), urgent care facility (POS 20), or emergency department (POS 23).
Emergency department physicians may report 99053 for services rendered between the hours of 10 p.m. and 8 a.m. The American College of Emergency Physicians fully supports this use of 99053, stating that this code is appropriate for late-night services, "especially given the nighttime practitioner availability costs typically incurred by all medical practices, including emergency medicine."
Article written by: By G. John Verhovshek, MA, CPC from: http://www.physicianspractice.com/blog/how-code-negotiate-after-hours-reimbursement-your-practice?utm_source=dlvr.it&utm_medium=twitter&mkt_tok=3RkMMJWWfF9wsRoluqXKZKXonjHpfsX57ugqXKS3lMI/0ER3fOvrPUfGjI4ETMNrI%2BSLDwEYGJlv6SgFSbXHMbl60bgMUhg%3D
Tuesday, August 13, 2013
Doctors favor care improvement strategies over financial reforms
A recent survey reveals acknowledgement among U.S. physicians that they have a role in helping to contain healthcare costs. The survey respondents generally support quality initiatives that may also reduce cost, but are less enthusiastic about cost containment involving changes in payment models. The study was published in the July 24/31 issue of the Journal of the American Medical Association.
“Because physicians' decisions play a key role in overall health care spending and quality, several recent initiatives have called on physicians to reduce waste and exercise wise stewardship of resources. Given their roles, physicians' perspectives on policies and strategies related to cost containment and their perceived responsibilities as stewards of healthcare resources in general are increasingly germane to recent pending and proposed policy reforms,” according to background information in the article.
Jon C. Tilburt, MD, MPH, of the Mayo Clinic, Rochester, Minn., and colleagues conducted a survey of physicians about their views on several potential proposed policies and strategies to contain healthcare spending, assessed physicians' perceived roles and responsibilities in addressing health care costs, and ascertained physician characteristics associated with those views.
The survey was mailed in 2012 to 3,897 U.S. physicians randomly selected from the American Medical Association Masterfile. A total of 2,556 physicians responded (65 percent response rate). The survey asked respondents to rate their level of enthusiasm (not, somewhat or very enthusiastic) toward 17 specific means of reducing healthcare costs, including but not limited to strategies proposed in the Affordable Care Act; and agreement with an 11-measure cost-consciousness scale.
The researchers found that most respondents believed that trial lawyers (60 percent), health insurance companies (59 percent), hospitals and health systems (56 percent), pharmaceutical and device manufacturers (56 percent) and patients (52 percent) have a “major responsibility” for reducing healthcare costs, whereas only 36 percent reported that practicing physicians have “major responsibility.” Most physicians were “very enthusiastic” for “promoting continuity of care” (75 percent), “expanding access to quality and safety data” (51 percent) and “limiting access to expensive treatments with little net benefit” (51 percent) as means of reducing healthcare costs.
Few respondents called for eliminating fee-for-service payment models (7 percent). “Most physicians reported being ‘aware of the costs of the tests/treatments [they] recommend’ (76 percent), agreed they should adhere to clinical guidelines that discourage the use of marginally beneficial care (79 percent), and agreed that they ‘should be solely devoted to individual patients' best interests, even if that is expensive’ (78 percent) and that ‘doctors need to take a more prominent role in limiting use of unnecessary tests’ (89 percent),” the authors wrote.
Most physicians (85 percent) disagreed that they “should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more.” In models testing associations with enthusiasm for key cost-containment strategies, having a salary plus bonus or salary-only compensation type was independently associated with enthusiasm for “eliminating fee for service.” Also, group or government practice setting and having a salary plus bonus compensation type were positively associated with cost-consciousness.
“U.S. physicians' opinions about their role in containing healthcare costs are complex. In this survey, we found that they express considerable enthusiasm for several proposed cost-containment strategies that aim to enhance or promote high-quality care such as improved continuity of care. However, there is considerably less enthusiasm for more substantial financing reforms, including bundled payments, penalties for readmissions, and eliminating fee-for-service reimbursement. Medicare pay cuts are unpopular across the board. They were also more likely to identify other groups, rather than physicians -- such as insurers, lawyers, hospitals and health systems -- as having a major responsibility to reduce cost. These data document professional sentiments about addressing healthcare costs and speak directly to the acceptability of several key policy strategies for curbing those costs,” the authors wrote.
“Moving toward cost-conscious care in the current environment in which physicians practice starts with strategies for which there is widespread physician support; [that] might create momentum for such efforts, including improving quality and efficiency of care and bringing transparent cost information and evidence from comparative effectiveness research into electronic health records with decision support technology. More aggressive (and potentially necessary) financing changes may need to be phased in, with careful monitoring to ensure that they do not infringe on the integrity of individual clinical relationships,” the authors added.
In an accompanying editorial titled "Will Physicians Lead on Controlling Health Care Costs?" Ezekiel J. Emanuel, MD, PhD, and Andrew Steinmetz of the University of Pennsylvania, wrote that the findings of this survey “are somewhat discouraging.”
“The findings suggest that physicians do not yet have that ‘all-hands-on-deck’ mentality this historical moment demands. Indeed, the survey…suggests that in the face of this new and uncertain moment in the reform of the health care system, physicians are lapsing into the well-known, cautious instinctual approaches humans adopt whenever confronted by uncertainty: blame others and persevere with ‘business as usual.’”
“The study by Tilburt et al indicates that the medical profession is not there yet — that many physicians would prefer to sit on the sidelines while other actors in the healthcare system do the real work of reform. This could marginalize and demote physicians. Physicians must commit themselves to act like the captain of the healthcare ship and take responsibility for leading the United States to a better healthcare system that provides higher-quality care at lower costs.”
Courtesy of: http://www.physbiztech.com/news/business/doctors-favor-care-improvement-strategies-over-financial-reforms?mkt_tok=3RkMMJWWfF9wsRoluqXKZKXonjHpfsX57ugqXKS3lMI/0ER3fOvrPUfGjI4ETMNrI%2BSLDwEYGJlv6SgFSbXHMbl60bgMUhg%3D
“Because physicians' decisions play a key role in overall health care spending and quality, several recent initiatives have called on physicians to reduce waste and exercise wise stewardship of resources. Given their roles, physicians' perspectives on policies and strategies related to cost containment and their perceived responsibilities as stewards of healthcare resources in general are increasingly germane to recent pending and proposed policy reforms,” according to background information in the article.
Jon C. Tilburt, MD, MPH, of the Mayo Clinic, Rochester, Minn., and colleagues conducted a survey of physicians about their views on several potential proposed policies and strategies to contain healthcare spending, assessed physicians' perceived roles and responsibilities in addressing health care costs, and ascertained physician characteristics associated with those views.
The survey was mailed in 2012 to 3,897 U.S. physicians randomly selected from the American Medical Association Masterfile. A total of 2,556 physicians responded (65 percent response rate). The survey asked respondents to rate their level of enthusiasm (not, somewhat or very enthusiastic) toward 17 specific means of reducing healthcare costs, including but not limited to strategies proposed in the Affordable Care Act; and agreement with an 11-measure cost-consciousness scale.
The researchers found that most respondents believed that trial lawyers (60 percent), health insurance companies (59 percent), hospitals and health systems (56 percent), pharmaceutical and device manufacturers (56 percent) and patients (52 percent) have a “major responsibility” for reducing healthcare costs, whereas only 36 percent reported that practicing physicians have “major responsibility.” Most physicians were “very enthusiastic” for “promoting continuity of care” (75 percent), “expanding access to quality and safety data” (51 percent) and “limiting access to expensive treatments with little net benefit” (51 percent) as means of reducing healthcare costs.
Few respondents called for eliminating fee-for-service payment models (7 percent). “Most physicians reported being ‘aware of the costs of the tests/treatments [they] recommend’ (76 percent), agreed they should adhere to clinical guidelines that discourage the use of marginally beneficial care (79 percent), and agreed that they ‘should be solely devoted to individual patients' best interests, even if that is expensive’ (78 percent) and that ‘doctors need to take a more prominent role in limiting use of unnecessary tests’ (89 percent),” the authors wrote.
Most physicians (85 percent) disagreed that they “should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more.” In models testing associations with enthusiasm for key cost-containment strategies, having a salary plus bonus or salary-only compensation type was independently associated with enthusiasm for “eliminating fee for service.” Also, group or government practice setting and having a salary plus bonus compensation type were positively associated with cost-consciousness.
“U.S. physicians' opinions about their role in containing healthcare costs are complex. In this survey, we found that they express considerable enthusiasm for several proposed cost-containment strategies that aim to enhance or promote high-quality care such as improved continuity of care. However, there is considerably less enthusiasm for more substantial financing reforms, including bundled payments, penalties for readmissions, and eliminating fee-for-service reimbursement. Medicare pay cuts are unpopular across the board. They were also more likely to identify other groups, rather than physicians -- such as insurers, lawyers, hospitals and health systems -- as having a major responsibility to reduce cost. These data document professional sentiments about addressing healthcare costs and speak directly to the acceptability of several key policy strategies for curbing those costs,” the authors wrote.
“Moving toward cost-conscious care in the current environment in which physicians practice starts with strategies for which there is widespread physician support; [that] might create momentum for such efforts, including improving quality and efficiency of care and bringing transparent cost information and evidence from comparative effectiveness research into electronic health records with decision support technology. More aggressive (and potentially necessary) financing changes may need to be phased in, with careful monitoring to ensure that they do not infringe on the integrity of individual clinical relationships,” the authors added.
In an accompanying editorial titled "Will Physicians Lead on Controlling Health Care Costs?" Ezekiel J. Emanuel, MD, PhD, and Andrew Steinmetz of the University of Pennsylvania, wrote that the findings of this survey “are somewhat discouraging.”
“The findings suggest that physicians do not yet have that ‘all-hands-on-deck’ mentality this historical moment demands. Indeed, the survey…suggests that in the face of this new and uncertain moment in the reform of the health care system, physicians are lapsing into the well-known, cautious instinctual approaches humans adopt whenever confronted by uncertainty: blame others and persevere with ‘business as usual.’”
“The study by Tilburt et al indicates that the medical profession is not there yet — that many physicians would prefer to sit on the sidelines while other actors in the healthcare system do the real work of reform. This could marginalize and demote physicians. Physicians must commit themselves to act like the captain of the healthcare ship and take responsibility for leading the United States to a better healthcare system that provides higher-quality care at lower costs.”
Courtesy of: http://www.physbiztech.com/news/business/doctors-favor-care-improvement-strategies-over-financial-reforms?mkt_tok=3RkMMJWWfF9wsRoluqXKZKXonjHpfsX57ugqXKS3lMI/0ER3fOvrPUfGjI4ETMNrI%2BSLDwEYGJlv6SgFSbXHMbl60bgMUhg%3D
Monday, August 5, 2013
Claims analysis shows doctors the way to fight insurer denials
Physician practices that are losing a significant amount of administrative time and revenue due to denied insurance claims may be able to reduce those losses by regularly conducting a claims denial analysis.
The analysis, which should be done on a monthly or quarterly basis, will reveal the main causes for denials, point out any patterns for denials per insurer and determine whether the errors or oversights were made by the insurance company or the physician’s staff. With this information in hand, practices can solve internal deficiencies through education and control, and decide which cases are worth appealing.
The result will be fewer denials and appeals. And that will mean more revenue for practices and more time for physicians and staff to concentrate on other things.
“You’re looking at 5% of claims denied every year for an average family practice, that’s about $30,000 walking out the door every year,” said Ryann Philpot, manager of revenue cycle management at e-MDs, a certified practice management software and solutions provider in Austin, Texas.
In its sixth annual National Health Insurer Report Card, released in June, the American Medical Association found that administrative tasks associated with errors, inefficiencies and waste in the medical claims process had an Administrative Burden Index cost per claim of $2.36 for physicians. The report card said denials dropped 47% in 2013 to an overall rate of 1.82%, and errors are down from about 20% in 2010 to 7.1%. However, the AMA estimates that more than $43 billion could have been saved since 2010 if commercial insurers had consistently paid claims correctly.
Kristin D. Drynan, MD, a family physician in a Geneva, Ill., practice with eight other doctors, said that although she hasn’t done a formal claims denial analysis, she recently began doing her own billing, checking for errors and denials in the claims process.
“I’ve seen a 7% to 10% increase in my receipts, which the other doctors haven’t seen,” she said.
Where to start
When conducting an analysis, the key is to organize denials by payer explanation of benefit reason and remark codes, said A.J. Johnson, director of reimbursement products for TriZetto Provider Solutions in Sacramento, Calif. He said the required codes from the payer should identify the reason for the denial, such as a patient eligibility issue or missing claim information. The next step is to organize the groups of codes into work flows such as claims data issues, patient responsibility and claims that may require an appeal or reconsideration from the insurer.
This will determine where the error was made, if it can be successfully appealed and how it can be corrected.
“Last year a series of claims was denied by one insurance company that didn’t make sense,” said Bill Gilbert, vice president of marketing for AdvantEdge Healthcare Solutions in Warren, N.J., which provides financial management, billing and coding services. “Through a series of phone calls we discovered that the company had an edit wrong in their system.”
The analysis, if done on a timely basis, could quickly uncover a pattern of denials, alerting a practice to a new rule established by an insurer without warning, said Taylor Moorehead, Western regional partner with Zotec Partners in Carmel, Ind., which specializes in medical billing and practice management services. He said it was discovered through an appeal that an insurance company denied claims if it wasn’t stated on the claim that the visit wasn’t due to a workers’ compensation case or auto accident. Practices weren’t notified about the insurer’s new policy.
Experts say the top three reasons for denial are patient ineligibility, medical necessity and coding errors.
With patient ineligibility, the insurance card may no longer be active, there could be a lapse in coverage or there could be an error in data entry, Philpot said. Patients also may not have been precertified and may have given their spouse’s insurance card by mistake. He recommends having each insurer’s guidelines on hand so office staff can easily access them.
Gilbert said front desk employees should look at the insurance card to make sure it matches the patient and is valid on that date, then make a copy of the card.
“I suggest to my clients that they ask the patient, particularly around the beginning or end of the year, if their insurance changed recently. During the recession, we saw a lot of changes in insurance companies as people lost jobs,” he said.
Johnson recommends practices send insurers an electronic eligibility request, which can provide a quick response on whether a patient is eligible before receiving services. Additional benefit information may let the practice know ahead of time, for example, that a patient is allowed only up to 10 physical therapy treatments, and the practice should bill the patient for any subsequent treatments.
Philpot said insurers might deny a claim on the basis of medical necessity if they don’t believe the diagnosis justifies the procedure. Richard Quadrino, a New York attorney who represents medical facilities fighting claim denials, said some insurance companies will see a doctor do a lot of the same procedure, believe the procedure was being abused and put an automatic edit into the computer not to pay for it.
Problems with coding
Dr. Drynan said she found in her own informal analysis that not being coded correctly goes hand in hand with not being considered medically necessary by insurance companies. Being in family practice, she said many of her patients come in for more than one symptom at a time, making the coding process difficult.
“There’s not an easy way to code on a multitask visit. It’s hard to code correctly unless you do it yourself,” Dr. Drynan said.
But Quadrino said insurers who deny claims based on their view of what is medically necessary may be violating the federal Employee Retirement Income Security Act of 1974. He said the law states that for any claim denied for medical necessity, investigational or experimental reasons, insurers must provide a scientific or clinical basis for their decision. Under ERISA, which Quadrino said was expanded under the Affordable Care Act to include large group health plans and their insurers, companies must make a decision on a claim within 30 days. A 15-day extension could be granted only for a good cause. If the insurer requests more information, it can get an additional 30 days.
Doing the claims denial analysis regularly will help a practice make any appeals in a timely fashion and determine whether it wants to appeal or ultimately drop the carrier.
“If a company doesn’t bend on its policy it would be a waste of time and money to appeal,” Moorehead said.
Quadrino said that although insurers frequently violate ERISA rules, a lot of doctors let it go rather than proceed to the appeals process. “Even in smaller practices this could mean the loss of a very large amount of money,” he said.
Brian Reese, director of new business relationships for medicalbillersandcoders.com based in Cleveland, said while claims denial analyses help practices improve their denial rates, they shouldn’t expect immediate results.
“It doesn’t happen right away,” he said. “You need to chisel away at it.”
Written By Karen Caffarini Courtesy of: http://www.amednews.com/article/20130715/business/130719992/5/?utm_source=rss&utm_medium=&utm_campaign=20130805Friday, August 2, 2013
Introducing Interactive Care Reviewer (ICR), By Anthem Blue Cross available on Availity
Anthem Blue Cross launches a new secure, online provider utilization management tool - register today!
With ICR, your practice can now initiate precertification requests online more efficiently and conveniently. Our new tool offers a streamlined precertification process, using cutting-edge IBM Watson™
technology. Access our ICR via Availity Web Portal to request outpatient procedures* for many members covered by Anthem Blue Cross plans.
With ICR, your practice can now initiate precertification requests online more efficiently and conveniently. Our new tool offers a streamlined precertification process, using cutting-edge IBM Watson™
technology. Access our ICR via Availity Web Portal to request outpatient procedures* for many members covered by Anthem Blue Cross plans.
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Wednesday, July 31, 2013
Follow This 3-Step Advice Before Waiving Copays
Follow This 3-Step Advice Before Waiving Copays
Tip: Get your own verification of financial hardship.
Every Physician wants to collect his due payment, even if it accumulates in small amounts through copays or deductible. Though you often hear advice pointing you away from offering discounts or waiving fees, there are times when that approach can be your best option. Our experts share three steps to properly waiving patient fees based on financial hardship.1. Understand the Exception to the Rule
Routinely waiving deductibles and copayments can violate several federal laws and regulations, including the federal False Claims Act, anti-kickback statutes, and compliance guidelines for individual and small group physician practices. Doing so may also violate payer contracts.In black and white: "Physicians or suppliers who routinely waive the collection of deductible or coinsurance from a beneficiary constitute a violation of the law pertaining to false claims and kickbacks," CMS says in the Medicare Claims Processing Manual, chapter 23, section 80.8.1. This applies not only to Medicare payers, but also those private carriers that base their regulations on Medicare rules.
Even though the rule is that you shouldn't offer waivers and discounts, you can make exceptions based on financial hardship-- if you follow a few guidelines.
"Waivers or discounts... should be made only on the basis of demonstrated patient financial need," says Barbara Colburn, president/CEO of B.C. & Associates Management Corp., a Wisconsin-based health care consulting/billing organization. According to Colburn, you must meet the following criteria:
- You do not offer the waiver as part of any advertisement or solicitation
- You do not offer waivers routinely to patients
"In offices that i managed we always had the option of a financial hardship waiver but it was usually offered only after all the other means of collecting were exhausted such as insurance, payment plans, etc." says Marge McQuade, CMSCS, CMM, a consultant in Florida.
Note: You can offer discounts to patients with no insurance who are self-paying without proving financial hardship. Offering waivers or discounts to insured patients, including Medicare patients, "may be suspect unless they are non-routine and related to genuine hardship," Colburn says.
Pointer: "Have a financial policy in place about how you handle patients with financial hardships," advises Catherine Brink, CMM, CPC, CMSCS, owner of HealthCare Resource Management, Inc., in Spring Lake, N.J. "This is very important since it ensures you don't 'discriminate' how you handle finances with your patients."
2. Get It in Writing
Don't just take the patients word for it when it comes to financial hardship. Before you agree to debt write-off, the patient needs to be able to prove he is unable to pay.First, document the effort you took to collect the money. "Where a physician/supplier makes a reasonable collection effort for the payment of coinsurance/deductible, failure to collect payment is not considered a reduction in the physician's/supplier's charge," CMS says in the Medicare Claims Processing Manual, chapter 23, section 80.8.1. "To be considered a reasonable collection effort, the effort to collect Medicare coinsurance/ deductible amounts must be similar to the effort made to collect comparable amounts from non-Medicare patients. It must also involve the issuance of a bill to the beneficiary or to the party responsible for the patients personal financial obligations. In addition, it may include other actions, such as subsequent billings, collection letter and telephone calls or personal contacts which constitute a genuine, rather than token, collections effort."
If you want to prove financial hardship, you'll need to ask the patient to provide you with information such as income tax returns and W-2 and 1099 forms as proof of income and essential monthly household expenditures, such as mortgage/rent, utilities, insurance, and food.
You'll then use this information to determine whether the patients earnings meet state and federal poverty guidelines. "Make sure you work within the poverty guidelines for your state," McQuade cautions.
Official Guidance: The Office of the Inspector General (IOG) states, "we do not believe it is appropriate to apply inflated income guidelines that result in waivers for beneficiaries who are not in genuine financial need."
The patient and the physician should also sign a statement detailing that the practice reviewed proof of financial hardship and listing what charges the practice is waiving. You practice should keep a copy and provide a copy to the patient as well.
"The provider should keep up with legal developments related to discounts and waivers of co-payments and deductibles," Colburn explains.
Key to success: You also should only apply the determination of financial hardship to the particular visit or service you are billing for at the time, not to any future services.
3. Don't Avoid Collections If Waiver Is a No Go
If a patient applies for financial hardship but your practice deems that the patient does not meet the qualifications for a waiver, you should send a waiver denial form. But don't let that stop your collections efforts and end up in a write off. You then need to proceed with billing the patient and letting him know you expect payment.Option: "If a patient applied for financial hardship and doesn't qualify, the next step would be to offer a payment plan for the patient, depending, of course, on the amount the patient owes and at what point you are doing the waiver (after insurance, self pay with payment plan first, etc.)," McQuade says.
"For example, ask for a credit card to keep on file that you would charge, say $50 each month," agrees Brink. "Have the patient sign this financial agreement." If the patient doesn't have a credit card, then set up a financial payment plan signed by the patient stating that he will pay by check or cash by a certain day of each month and the amount he will pay plus the date the balance will be paid in full, Brink adds.
Courtesy of: The Coding Institute: Family Practice Coding Alert
Friday, July 26, 2013
5 Best Practices for Using Payment Plans to Ensure Patient Payments
5 Best Practices for Using Payment Plans to Ensure Patient Payments
What You Need to Know
An article by Bill Marvin, taken from the May/June issue of HBMA Billing (hbma.org)As health insurance premiums continue to grow (at an average annual rate of 7.1 percent [AHIP 2010]), employers are switching to lower cost, high-deductible health plans. This trend is resulting in an overall decrease in payor payments and a consequent increase in patient payments. This will continue throughout the next decade as the Affordable Care Act rolls out. As a result, billing services and their clients are more dependent on patients for revenue. To collect more from patients, many billing services have started to use patient-centered strategies, such as payment plans. However, to improve results and increase efficiency for their clients, billing services need to ensure that they have implemented best practices.
A Growing Trend
Data from the 2011 "Trends in Healthcare Payments" report shows that the use of payment plans for healthcare payments has doubled since 2009.1 In the same report, 63 percent of surveyed patients said that they would utilize payment plans for their healthcare bills if given the option.
Five Best Practices for Successful Payment Plans
- Automate Payments
Many billing services support payment plans manually by managing a calendar that shows when each payment is owed and by calling patients to collect every month. This method is a step in the right direction, but it adds to the billing service's work effort, does not ensure payment for the client, and has security flaws. Whether the payment plan is set up while the patient is in the office or after a statement is sent, billing services and their clients should securely collect and store payment information so they can automatically collect payments when they are due. - Automate Communications
Even when a patient authorizes automated monthly payments, he or she may still forget about the payment until it shows up on their next statement, which may create confusion and costly chargebacks. Improve communication and offer payment transparency by automating email notifications to patients prior to each payment transaction
Tip: Provide clients with a one-page "FAQ" for patients explaining how payment plans work, including payment timing, notifications, and payment card security. - Draw a Line
It is great for billing services to give patients some flexibility and choice in how much they pay each month, but it is also necessary that they set parameters and stick to them. As a standard best practice, billing services should charge a minimum monthly payment of $100 or require that the bill be paid in full within 12 months. - Collect Something Upfront
Payment plans work well for patients who are unable to pay the full bill at once, but billing services should avoid allowing payment plans to become a way for patients to put off paying at all. Establish a policy that patients must pay a certain percentage of the bill upon setting up a monthly payment plan. - Tailor Payment Plans to Patient Needs
Depending on the scenario, there are three main types of payment plans to offer patients:- Installment: Collect payments against an outstanding balance and deactivate the plan automatically when the total balance is paid.
- Recurring: Collect payments at a regular, ongoing interval as a subscription service.
- Save on File: Save a patient's payment card on file to collect the remaining amount owed when the claim is adjudicated. This is useful when the patient's payment responsibility is unknown during the patient visit; for example, if the patient has a high deductible.
By following best practices when offering patient payment plans, billing services can ensure payment for their clients, even from self-pay or high-deductible patients. Automated, scheduled payment plans save billing services a lot of time and costs to send multiple patient statements and make follow-up calls to patients as well as improve patient communication and clarity around the payment process.
Commercial Payor News - Health Insurance Plan Links
Commercial Payor News - Health Insurance Plan Links
AEGON USA, Inc.
http://www.aegonins.com/
Aetna, Inc.
http://www.aetna.com/index.htm
Affinity Health Plan
http://www.affinityplan.org/
Aflac
http://www.aflac.com/
Alameda Alliance for Health
http://alamedaalliance.org/
Alere Medical, Inc.
www.alere.com
Allegiance Life & Health Insurance Company
http://www.allegiancelifeandhealth.com/
AlohaCare
http:// www.alohacare.com
AMA Insurance Agency
http://www.ama-assn.org/
American Fidelity Assurance Company
http://www.af-group.com/
American Heritage Life
http://www.allstate.com
American Medical Security, Inc.
http://www.eams.com/
American Republic Insurance Company
http://www.aric.com/
American Specialty Health Incorporated
http://www.ashcompanies.com/
AmeriChoice Health Services, Inc.
http://www.americhoice.com
Amerigroup Corporation
http://www.amerigroupcorp.com/
AmeriHealth
http://www.amerihealth.com
Arcadian Health Plans
www.arcadianhp.com
Arkansas BlueCross Blue Shield
http://www.arkbluecross.com
Assurant Health
http://www.assuranthealth.com
AultCare Corporation
http://www.aultcare.com/
Avera Health Plans
www.averahealthplans.com
AvMed Health Plan
http://www.avmed.org
Aveta, Inc
http://www.aveta.com
Axis Global Accident & Health
www.axiscapital.com/accident
Bankers Life and Casualty Company
http://www.bankerslife.com
Blue Cross Blue Shield of Arizona
http://www.bcbsaz.com
Blue Cross and Blue Shield of Florida
http://www.bcbsfl.com/home/index.cfm
Blue Cross and Blue Shield of Georgia
http://www.bcbsga.org/
Blue Cross Blue Shield of Kansas
http://www.bcbsks.com
Blue Cross and Blue Shield of Illinois
http://www.bcbsil.com
Blue Cross & Blue Shield of Louisiana
http://www.bcbsla.com
Blue Cross Blue Shield of Michigan
http://www.bcbsm.com
Blue Cross and Blue Shield of Minnesota
http://www.bluecrossmn.com
Blue Cross and Blue Shield of Montana
http://www.bcbsmt.com/
Blue Cross and Blue Shield of New Mexico
http://www.bcbsnm.com
Blue Cross Blue Shield of Massachusetts
http://www.bcbsma.com
Blue Cross Blue Shield of Nebraska
http://www.bcbsne.com
Blue Cross Blue Shield of North Carolina
http://www.bcbsnc.com
BlueCross BlueShield of North Dakota
http://www.bcbsnd.com
BlueCross BlueShield of Oklahoma
http://www.bcbsok.com/
Blue Cross and Blue Shield of Rhode Island
www.bcbsri.com
BlueCross BlueShield of South Carolina
http://www.bcbssc.com
BlueCross BlueShield of Tennessee
http://www.bcbst.com
BlueCross BlueShield of Texas
http://www.bcbstx.com
BlueCross BlueShield of Vermont
http://www.bcbsvt.com
BlueShield of Northeastern New York
http://www.bsneny.com
Blue Cross of Idaho
http://www.bcidaho.com
Blue Cross of Northeastern Pennsylvania
http://www.bcnepa.com
Blue Shield of California
http://www.blueshieldca.com
Bluegrass Family Health, Inc.
http://www.bgfh.com
Boston Medical Center Healthnet Plan
http:// www.bmchp.org
Bravo Health
http:// www.bravohealth.com
CalOptima
http://www.caloptima.org
Capital Blue Cross
http://www.capbluecross.com/
Capital District Physicians´ Health Plan
http://www.cdphp.com
Capstone Health Plan, Inc.
www.nazcap.com
Care 1st Health Plan
http//www.care1st.com/
CareFirst BlueCross BlueShield
http://www.carefirst.com
CareMore Health Plan
http://www.caremore.org
CareOregon
http://www.careoregon.org
CareSource
http://www.caresource.com
Celtic Insurance Company
http://www.celtic-net.com/
CENTENE Corp.
http://www.centene.com
Chartered Health Plan
http://www.chartered-health.com/
Children's Mercy Family Health Partners
http://www.fhp.org
Chinese Community Health Plan
http://www.cchphmo.com
CIGNA Health Carehttp://www.cigna.com/
CNO Financial Group
http://cnoinc.com/
Colorado Choice Health Plans/San Luis Valley HMO
http://www.slvhmo.com
Commercial Travelers Mutual Insurance Company
http://www.commercialtravelers.com/
Community Care, Inc.
http://www.communitycareinc.org/
Community Health Network of Connecticut
http://www.chnct.org/
Community Health Partnership
http://www.communityhealthpartnership.com
Community Health Plan of Washington
http://www.chpw.org
ConnectiCare, Inc.
http://www.connecticare.com/
CoreSource
http://www.coresource.com/
Coventry Health Care, Inc.
http://www.cvty.com
DAKOTACARE
http://www.dakotacare.com
Dean Health Plan, Inc.
http://www.deancare.com
Delta Dental Plans Association
http://www.deltadental.com/
Denver Health Medical Plan
http://www.denverhealth.org
Disability Management Services, Inc.
http://www.disabilitymanagementservices.com
Elderplan
http://www.mjhs.org
Empire Blue Cross and Blue Shield
http://empireblue.com
ENCOMPASS Health Management Systems
http://www.encompas.com
Erickson Advantage
http://www.ericksonadvantage.com/
Essence, Inc
http://www.essencehealthcare.com
Excellus BlueCross BlueShield
http://www.excellusbcbs.com
Fallon Community Health Plan
http://www.fchp.org
Family Care, Inc.
http://www.familycareinc.org/
Federated Insurance Companies
http://www.federatedinsurance.com/
FirstCarolina Care, Inc.
http://www.firstcarolinacare.com/
First Choice Health Network
http://www.1stchoiceofwa.com
First Health
http://www.firsthealth.com/
Florida Hospital Healthcare System
http://www.flhosp.org
Fresenius Medical Care Health Plan
http://www.fmchp.com
Geisinger Health Plans
http://www.thehealthplan.com/
Gen Re LifeHealthhttp://www.genre.com/
Genworth Financial
http://www.genworth.com/longtermcare
Group Health Cooperative
http://www.ghc.org/
Group Health Cooperative of Eau Claire
http://www.group-health.com/
Group Health Cooperative of SC Wisconsin
http://www.ghc-hmo.com
Group Health Incorporated
http://www.ghi.com
Guarantee Trust Life Insurance Company
http://www.gtlic.com/
Guardian Life Insurance Company of America, The
http://www.glic.com/
Guildnet, Inc.
http://www.jgb.org
Gundersen Lutheran Health Plan Inc.
http://www.gundluth.org/healthplan
Harvard Pilgrim Health Care
http://www.hphc.org
Health Alliance Medical Plan
http://www.healthalliance.org
Health Alliance Plan
http://www.hap.org
Health Dialog
http://www.healthdialog.com/
Health First Health Plan, Inc.
http://www.health-first.org/health_plans
Health Net
http://www.healthnet.com
Health New England
http://www.healthnewengland.com
Health Partners – Philadelphia
http://www.healthpart.com
Health Plan of Michigan
http://www.hpmich.com/
Health Plan of Nevada
http://www.healthplanofnevada.com/
Health Plan of San Joaquin
http://www.hpsj.com
Health Tradition Health Plan
http://www.healthtradition.com
HealthEquity
http://www.healthequity.com
Healthfirst, Inc.
http://www.healthfirstny.com
HealthMarkets
http://www.healthmarkets.com
HealthNow of New York, Inc.
http://www.healthnowny.com/
HealthPartners, Inc.
http://www.healthpartners.com
HealthPlan Services
http://www.healthplan.com
HealthPlus of Michigan
http://www.healthplus.com/providers.html
HealthSpring
http://www.myhealthspring.com
Healthways, Inc.
http://www.healthways.com
Highmark Blue Cross Blue Shield
http://www.highmark.com
HIP Health Plans
http://www.hipusa.com
Hometown Health Plan
http://www.hometownhealth.com/
Horizon BC/BS of New Jersey
http://www.horizon-bcbsnj.com
Humana, Inc.
http://www.humana.com/
Illinois Mutual Life Insurance Company
http://www.illinoismutual.com/
The i/mx* Companies
http://www.imxinc.com
Independence Blue Cross, Philadelphia, PA
http://www.ibx.com
Independent Health
http://www.independenthealth.com
Insurance Administrative Solutions, L.L.C.
http://www.wakelyinc.com
Integrated Health Plan
http://www.ihplan.com
Inter Valley Health Plan
http://www.ivhp.com IU Health
http://iuhealth.org JHA, Inc.
http://www.jhaweb.com/
John Hancock Financial Services
http:// www.jhancock.com
Kaiser Permanente
http://www.kp.org/
KelseyCare Advantage
www.kelseycareadvantage.com
Kern Health Systems
http://www.kernhealthsystems.com
Keystone Mercy Health Plan, Inc.
http://www.keystonemercy.com
L.A. Care
http://www.lacare.org
LifeCare Assurance Company
http://www.lifecareassurance.com/
LifePlans, Inc.
http://www.lifeplansinc.com/
The Lifetime Healthcare Companies
http://www.lifethc.com
Univita Health
www.univitahealth.com
Long Term Care Partners, LLC
http://www.ltcfeds.com/
Lovelace Sandia Health System/Lovelace Health Plan
http://www.lovelacehealthplan.com
Martin's Point Health Care
http://www.martinspoint.com
MedAmerica Insurance Company
http://www.medamericaltc.com/
Medco
http://www.medcohealth.com
Medica Health Plan
http://www.medica.com
Medical Benefits Mutual Life Insurance Co.
http://www.medben.com
Medical Mutual of Ohio
http://www.medmutual.com
MemberHealth
http://www.mhrx.com
Mercy Health Plans
http://www.mercyhealthplans.com
Metlife
http://www.metlife.com
Metropolitan Health Plan
http://www.co.hennepin.mn.us/
Mid Rogue Health Plan
http:// www.mripa.org
Molina Healthcare
http://www.molinahealthcare.com
Mount Carmel Health Plan
http://www.mountcarmelhealth.com/
MultiPlan, Inc.
http://www.multiplan.com
Munich Re America HealthCare
http://www.mrahc.com
Mutual of Omaha Insurance Company
http://www.mutualofomaha.com/
MVP Health Care
http://www.mvphealthcare.com
National Teachers Associates Life Insurance Company
http://www.ntalife.com
Nationwide Life Insurance Company
http://www.nationwide.com
Neighborhood Health Plan
http://www.nhp.org
Neighborhood Health Plan of Rhode Island
http://www.nhpri.org/
Neighborhood Health Providers
http://www.royalhc.com
Network Health Plan
http://www.networkhealth.com
New West Health Services
http://www.newwesthealth.com/
New York Life Insurance Company
http://www.newyorklife.com/
The ODS Companies
http://www.odscompanies.com
Olympic Health Management Systems, Inc.
http://www.ohmsystems.com/
On Lok Senior Health Services
http://www.onlok.org
Optum Health
http://www.optumcare.com/
PacificSource Health Plans
http://www.pacificsource.com
Passport Health Plan
http://www.passporthealthplan.com
PayFlex
www.payflex.com
Penn Highlands Health Plan
http://www.pennhighlands.com/
Penn Treaty American Corporation
http://www.penntreaty.com/
Peoples Health
http://www.peopleshealth.com
Physicians' Benefits Trust Life Insurance Co.
http://www.pbtinsurance.com
Physicians Health Plan of Northern Indiana
http://www.phpni.com
Physicians Mutual Insurance Company
http://www.physiciansmutual.com
PHP Companies d/b/a Cariten Healthcare
http://www.cariten.com
Preferred Care Partners
http://www.psohealth.com
Preferred Health Systems
http://www.phsystems.com/
PreferredOne
http://www.preferredone.com
Presbyterian Health Plan
http://www.phs.org
PrimeWest Health Systems
http://www.primewest.org
Principal Financial Group
http://www.principal.com
Providence Health Plans
http://www.providence.org/healthplans
Prudential Life Insurance Co. of America
http://www.prudential.com
Puget Sound Health Partners
http://www.ourpshp.com
QualCare, Inc.
http://www.qualcareinc.com
QualChoice of Arkansas
http://www.qualchoice.com
Regence BC/BS of Oregon
http://www.or.regence.com
Regence BlueCross BlueShield of Utah
http://www.regence.com
Regence Blue Shield
http://www.wa.regence.com
Regence BlueShield of Idaho
http://www.regence.com
Resolution Health
http://www.resolutionhealth.com
Rocky Mountain Health Plans
http://www.rmhp.org
Samaritan Health Plans
http://www.samaritanhealthplans.com/
San Francisco Health Plan
http://www.sfhp.org
SCAN Health Plan
http://www.scanhealthplan.com/
Scott & White Health Plan
http://www.sw.org
Senior Health Insurance Company of Pennsylvania
http://www.shipltc.com/
Senior Whole Health, LLC
http://www.seniorwholehealth.com
Sentara Healthcare
http://www.sentara.com/
Sharp Health Plan
http://www.sharp.com
Silver Script Insurance Company
http://www.silverscript.com
Southeastern Indiana Health Organization
http://www.siho.org
Starmark
http://www.starmarkinc.com/
State Farm Insurance Companies
http://www.statefarm.com/
Sterling Life Insurance Company
http://www.sterlingplans.com
Stonebridge Life Insurance Company
http://www.stonebridgelife.com/
Sun Health MediSun, Inc.
http://sunhealth.org
TakeCare Insurance Co.
http://www.takecareasia.com/
Teachers Protective Mutual Life Insurance Company
http://www.tpmins.com/
Thrivent Financial for Lutherans
http://www.thrivent.com
Touchstone Health Partnership, Inc.
http://www.touchstone-health.com
Transamerica Life Insurance Company
http://www.transamerica.com
Trillium Community Health Plan
http://www.trilliumchp.com
TriWest Healthcare Alliance
http://www.triwest.com/
Tufts Health Plan
http://www.tufts-healthplan.com
Trustmark Insurance Company
http://www.trustmarkinsurance.com/
UCare
http://www.ucare.org
UMR
http://www.umr.com
UNICARE Life & Health Insurance Company
http://www.unicare.com
United HealthCare
http://www.UnitedHealthcare.com
United Teacher Associates Insurance Company
http://www.utainteractive.com
UnitedHealth Group
http://www.unitedhealthgroup.com
Unity Health Plans
http://www.unityhealth.com
Unison Administrative Services
http://www.unisonhealthplan.com
Univera Healthcare
http://www.univerahealthcare.org
Universal American Corp
http://www.uafc.com
University Health Alliance
http://www.uhahealth.com
Universal Health Care
http://www.univhc.com
Unum Group
http://www.unum.com
UPMC Health Plan
http://www.upmc.edu
Upper Peninsula Health Plan
http://www.uphp.com
USAA Life Insurance Company
http://www.usaa.com
USHEALTH Group, Inc.
http://www.ushealthgroup.com
Virginia Premier
http://www.virginiapremier.com
VNS Choice
http://www.vnschoice.org
Vytra Health Plans
http://www.vytra.com
Wakely and Associates
http://www.wakelyinc.com/
WellCare Health Plans
http://www.wellcare.com
Wells Fargo
http://www.wellsfargo.com
WellPoint, Inc.
http://www.wellpoint.com
Western Health Advantage
http://www.westernhealthadvantage.com
WINHealth Partners
http://www.winhealthpartners.org
World Insurance Company
http://www.worldinsco.com
XL Health
http://www.xlhealth.com
Yale University Health Services
http://www.yale.edu/yuhs/menu.html
Zurich North America
http://www.zurichus.com/
Courtesy of: HBMA http://www.hbma.org/news/commercial-payor-resources/health-insurance-plan-links
http://www.aegonins.com/
Aetna, Inc.
http://www.aetna.com/index.htm
Affinity Health Plan
http://www.affinityplan.org/
Aflac
http://www.aflac.com/
Alameda Alliance for Health
http://alamedaalliance.org/
Alere Medical, Inc.
www.alere.com
Allegiance Life & Health Insurance Company
http://www.allegiancelifeandhealth.com/
AlohaCare
http:// www.alohacare.com
AMA Insurance Agency
http://www.ama-assn.org/
American Fidelity Assurance Company
http://www.af-group.com/
American Heritage Life
http://www.allstate.com
American Medical Security, Inc.
http://www.eams.com/
American Republic Insurance Company
http://www.aric.com/
American Specialty Health Incorporated
http://www.ashcompanies.com/
AmeriChoice Health Services, Inc.
http://www.americhoice.com
Amerigroup Corporation
http://www.amerigroupcorp.com/
AmeriHealth
http://www.amerihealth.com
Arcadian Health Plans
www.arcadianhp.com
Arkansas BlueCross Blue Shield
http://www.arkbluecross.com
Assurant Health
http://www.assuranthealth.com
AultCare Corporation
http://www.aultcare.com/
Avera Health Plans
www.averahealthplans.com
AvMed Health Plan
http://www.avmed.org
Aveta, Inc
http://www.aveta.com
Axis Global Accident & Health
www.axiscapital.com/accident
Bankers Life and Casualty Company
http://www.bankerslife.com
Blue Cross Blue Shield of Arizona
http://www.bcbsaz.com
Blue Cross and Blue Shield of Florida
http://www.bcbsfl.com/home/index.cfm
Blue Cross and Blue Shield of Georgia
http://www.bcbsga.org/
Blue Cross Blue Shield of Kansas
http://www.bcbsks.com
Blue Cross and Blue Shield of Illinois
http://www.bcbsil.com
Blue Cross & Blue Shield of Louisiana
http://www.bcbsla.com
Blue Cross Blue Shield of Michigan
http://www.bcbsm.com
Blue Cross and Blue Shield of Minnesota
http://www.bluecrossmn.com
Blue Cross and Blue Shield of Montana
http://www.bcbsmt.com/
Blue Cross and Blue Shield of New Mexico
http://www.bcbsnm.com
Blue Cross Blue Shield of Massachusetts
http://www.bcbsma.com
Blue Cross Blue Shield of Nebraska
http://www.bcbsne.com
Blue Cross Blue Shield of North Carolina
http://www.bcbsnc.com
BlueCross BlueShield of North Dakota
http://www.bcbsnd.com
BlueCross BlueShield of Oklahoma
http://www.bcbsok.com/
Blue Cross and Blue Shield of Rhode Island
www.bcbsri.com
BlueCross BlueShield of South Carolina
http://www.bcbssc.com
BlueCross BlueShield of Tennessee
http://www.bcbst.com
BlueCross BlueShield of Texas
http://www.bcbstx.com
BlueCross BlueShield of Vermont
http://www.bcbsvt.com
BlueShield of Northeastern New York
http://www.bsneny.com
Blue Cross of Idaho
http://www.bcidaho.com
Blue Cross of Northeastern Pennsylvania
http://www.bcnepa.com
Blue Shield of California
http://www.blueshieldca.com
Bluegrass Family Health, Inc.
http://www.bgfh.com
Boston Medical Center Healthnet Plan
http:// www.bmchp.org
Bravo Health
http:// www.bravohealth.com
CalOptima
http://www.caloptima.org
Capital Blue Cross
http://www.capbluecross.com/
Capital District Physicians´ Health Plan
http://www.cdphp.com
Capstone Health Plan, Inc.
www.nazcap.com
Care 1st Health Plan
http//www.care1st.com/
CareFirst BlueCross BlueShield
http://www.carefirst.com
CareMore Health Plan
http://www.caremore.org
CareOregon
http://www.careoregon.org
CareSource
http://www.caresource.com
Celtic Insurance Company
http://www.celtic-net.com/
CENTENE Corp.
http://www.centene.com
Chartered Health Plan
http://www.chartered-health.com/
Children's Mercy Family Health Partners
http://www.fhp.org
Chinese Community Health Plan
http://www.cchphmo.com
CIGNA Health Carehttp://www.cigna.com/
CNO Financial Group
http://cnoinc.com/
Colorado Choice Health Plans/San Luis Valley HMO
http://www.slvhmo.com
Commercial Travelers Mutual Insurance Company
http://www.commercialtravelers.com/
Community Care, Inc.
http://www.communitycareinc.org/
Community Health Network of Connecticut
http://www.chnct.org/
Community Health Partnership
http://www.communityhealthpartnership.com
Community Health Plan of Washington
http://www.chpw.org
ConnectiCare, Inc.
http://www.connecticare.com/
CoreSource
http://www.coresource.com/
Coventry Health Care, Inc.
http://www.cvty.com
DAKOTACARE
http://www.dakotacare.com
Dean Health Plan, Inc.
http://www.deancare.com
Delta Dental Plans Association
http://www.deltadental.com/
Denver Health Medical Plan
http://www.denverhealth.org
Disability Management Services, Inc.
http://www.disabilitymanagementservices.com
Elderplan
http://www.mjhs.org
Empire Blue Cross and Blue Shield
http://empireblue.com
ENCOMPASS Health Management Systems
http://www.encompas.com
Erickson Advantage
http://www.ericksonadvantage.com/
Essence, Inc
http://www.essencehealthcare.com
Excellus BlueCross BlueShield
http://www.excellusbcbs.com
Fallon Community Health Plan
http://www.fchp.org
Family Care, Inc.
http://www.familycareinc.org/
Federated Insurance Companies
http://www.federatedinsurance.com/
FirstCarolina Care, Inc.
http://www.firstcarolinacare.com/
First Choice Health Network
http://www.1stchoiceofwa.com
First Health
http://www.firsthealth.com/
Florida Hospital Healthcare System
http://www.flhosp.org
Fresenius Medical Care Health Plan
http://www.fmchp.com
Geisinger Health Plans
http://www.thehealthplan.com/
Gen Re LifeHealthhttp://www.genre.com/
Genworth Financial
http://www.genworth.com/longtermcare
Group Health Cooperative
http://www.ghc.org/
Group Health Cooperative of Eau Claire
http://www.group-health.com/
Group Health Cooperative of SC Wisconsin
http://www.ghc-hmo.com
Group Health Incorporated
http://www.ghi.com
Guarantee Trust Life Insurance Company
http://www.gtlic.com/
Guardian Life Insurance Company of America, The
http://www.glic.com/
Guildnet, Inc.
http://www.jgb.org
Gundersen Lutheran Health Plan Inc.
http://www.gundluth.org/healthplan
Harvard Pilgrim Health Care
http://www.hphc.org
Health Alliance Medical Plan
http://www.healthalliance.org
Health Alliance Plan
http://www.hap.org
Health Dialog
http://www.healthdialog.com/
Health First Health Plan, Inc.
http://www.health-first.org/health_plans
Health Net
http://www.healthnet.com
Health New England
http://www.healthnewengland.com
Health Partners – Philadelphia
http://www.healthpart.com
Health Plan of Michigan
http://www.hpmich.com/
Health Plan of Nevada
http://www.healthplanofnevada.com/
Health Plan of San Joaquin
http://www.hpsj.com
Health Tradition Health Plan
http://www.healthtradition.com
HealthEquity
http://www.healthequity.com
Healthfirst, Inc.
http://www.healthfirstny.com
HealthMarkets
http://www.healthmarkets.com
HealthNow of New York, Inc.
http://www.healthnowny.com/
HealthPartners, Inc.
http://www.healthpartners.com
HealthPlan Services
http://www.healthplan.com
HealthPlus of Michigan
http://www.healthplus.com/providers.html
HealthSpring
http://www.myhealthspring.com
Healthways, Inc.
http://www.healthways.com
Highmark Blue Cross Blue Shield
http://www.highmark.com
HIP Health Plans
http://www.hipusa.com
Hometown Health Plan
http://www.hometownhealth.com/
Horizon BC/BS of New Jersey
http://www.horizon-bcbsnj.com
Humana, Inc.
http://www.humana.com/
Illinois Mutual Life Insurance Company
http://www.illinoismutual.com/
The i/mx* Companies
http://www.imxinc.com
Independence Blue Cross, Philadelphia, PA
http://www.ibx.com
Independent Health
http://www.independenthealth.com
Insurance Administrative Solutions, L.L.C.
http://www.wakelyinc.com
Integrated Health Plan
http://www.ihplan.com
Inter Valley Health Plan
http://www.ivhp.com IU Health
http://iuhealth.org JHA, Inc.
http://www.jhaweb.com/
John Hancock Financial Services
http:// www.jhancock.com
Kaiser Permanente
http://www.kp.org/
KelseyCare Advantage
www.kelseycareadvantage.com
Kern Health Systems
http://www.kernhealthsystems.com
Keystone Mercy Health Plan, Inc.
http://www.keystonemercy.com
L.A. Care
http://www.lacare.org
LifeCare Assurance Company
http://www.lifecareassurance.com/
LifePlans, Inc.
http://www.lifeplansinc.com/
The Lifetime Healthcare Companies
http://www.lifethc.com
Univita Health
www.univitahealth.com
Long Term Care Partners, LLC
http://www.ltcfeds.com/
Lovelace Sandia Health System/Lovelace Health Plan
http://www.lovelacehealthplan.com
Martin's Point Health Care
http://www.martinspoint.com
MedAmerica Insurance Company
http://www.medamericaltc.com/
Medco
http://www.medcohealth.com
Medica Health Plan
http://www.medica.com
Medical Benefits Mutual Life Insurance Co.
http://www.medben.com
Medical Mutual of Ohio
http://www.medmutual.com
MemberHealth
http://www.mhrx.com
Mercy Health Plans
http://www.mercyhealthplans.com
Metlife
http://www.metlife.com
Metropolitan Health Plan
http://www.co.hennepin.mn.us/
Mid Rogue Health Plan
http:// www.mripa.org
Molina Healthcare
http://www.molinahealthcare.com
Mount Carmel Health Plan
http://www.mountcarmelhealth.com/
MultiPlan, Inc.
http://www.multiplan.com
Munich Re America HealthCare
http://www.mrahc.com
Mutual of Omaha Insurance Company
http://www.mutualofomaha.com/
MVP Health Care
http://www.mvphealthcare.com
National Teachers Associates Life Insurance Company
http://www.ntalife.com
Nationwide Life Insurance Company
http://www.nationwide.com
Neighborhood Health Plan
http://www.nhp.org
Neighborhood Health Plan of Rhode Island
http://www.nhpri.org/
Neighborhood Health Providers
http://www.royalhc.com
Network Health Plan
http://www.networkhealth.com
New West Health Services
http://www.newwesthealth.com/
New York Life Insurance Company
http://www.newyorklife.com/
The ODS Companies
http://www.odscompanies.com
Olympic Health Management Systems, Inc.
http://www.ohmsystems.com/
On Lok Senior Health Services
http://www.onlok.org
Optum Health
http://www.optumcare.com/
PacificSource Health Plans
http://www.pacificsource.com
Passport Health Plan
http://www.passporthealthplan.com
PayFlex
www.payflex.com
Penn Highlands Health Plan
http://www.pennhighlands.com/
Penn Treaty American Corporation
http://www.penntreaty.com/
Peoples Health
http://www.peopleshealth.com
Physicians' Benefits Trust Life Insurance Co.
http://www.pbtinsurance.com
Physicians Health Plan of Northern Indiana
http://www.phpni.com
Physicians Mutual Insurance Company
http://www.physiciansmutual.com
PHP Companies d/b/a Cariten Healthcare
http://www.cariten.com
Preferred Care Partners
http://www.psohealth.com
Preferred Health Systems
http://www.phsystems.com/
PreferredOne
http://www.preferredone.com
Presbyterian Health Plan
http://www.phs.org
PrimeWest Health Systems
http://www.primewest.org
Principal Financial Group
http://www.principal.com
Providence Health Plans
http://www.providence.org/healthplans
Prudential Life Insurance Co. of America
http://www.prudential.com
Puget Sound Health Partners
http://www.ourpshp.com
QualCare, Inc.
http://www.qualcareinc.com
QualChoice of Arkansas
http://www.qualchoice.com
Regence BC/BS of Oregon
http://www.or.regence.com
Regence BlueCross BlueShield of Utah
http://www.regence.com
Regence Blue Shield
http://www.wa.regence.com
Regence BlueShield of Idaho
http://www.regence.com
Resolution Health
http://www.resolutionhealth.com
Rocky Mountain Health Plans
http://www.rmhp.org
Samaritan Health Plans
http://www.samaritanhealthplans.com/
San Francisco Health Plan
http://www.sfhp.org
SCAN Health Plan
http://www.scanhealthplan.com/
Scott & White Health Plan
http://www.sw.org
Senior Health Insurance Company of Pennsylvania
http://www.shipltc.com/
Senior Whole Health, LLC
http://www.seniorwholehealth.com
Sentara Healthcare
http://www.sentara.com/
Sharp Health Plan
http://www.sharp.com
Silver Script Insurance Company
http://www.silverscript.com
Southeastern Indiana Health Organization
http://www.siho.org
Starmark
http://www.starmarkinc.com/
State Farm Insurance Companies
http://www.statefarm.com/
Sterling Life Insurance Company
http://www.sterlingplans.com
Stonebridge Life Insurance Company
http://www.stonebridgelife.com/
Sun Health MediSun, Inc.
http://sunhealth.org
TakeCare Insurance Co.
http://www.takecareasia.com/
Teachers Protective Mutual Life Insurance Company
http://www.tpmins.com/
Thrivent Financial for Lutherans
http://www.thrivent.com
Touchstone Health Partnership, Inc.
http://www.touchstone-health.com
Transamerica Life Insurance Company
http://www.transamerica.com
Trillium Community Health Plan
http://www.trilliumchp.com
TriWest Healthcare Alliance
http://www.triwest.com/
Tufts Health Plan
http://www.tufts-healthplan.com
Trustmark Insurance Company
http://www.trustmarkinsurance.com/
UCare
http://www.ucare.org
UMR
http://www.umr.com
UNICARE Life & Health Insurance Company
http://www.unicare.com
United HealthCare
http://www.UnitedHealthcare.com
United Teacher Associates Insurance Company
http://www.utainteractive.com
UnitedHealth Group
http://www.unitedhealthgroup.com
Unity Health Plans
http://www.unityhealth.com
Unison Administrative Services
http://www.unisonhealthplan.com
Univera Healthcare
http://www.univerahealthcare.org
Universal American Corp
http://www.uafc.com
University Health Alliance
http://www.uhahealth.com
Universal Health Care
http://www.univhc.com
Unum Group
http://www.unum.com
UPMC Health Plan
http://www.upmc.edu
Upper Peninsula Health Plan
http://www.uphp.com
USAA Life Insurance Company
http://www.usaa.com
USHEALTH Group, Inc.
http://www.ushealthgroup.com
Virginia Premier
http://www.virginiapremier.com
VNS Choice
http://www.vnschoice.org
Vytra Health Plans
http://www.vytra.com
Wakely and Associates
http://www.wakelyinc.com/
WellCare Health Plans
http://www.wellcare.com
Wells Fargo
http://www.wellsfargo.com
WellPoint, Inc.
http://www.wellpoint.com
Western Health Advantage
http://www.westernhealthadvantage.com
WINHealth Partners
http://www.winhealthpartners.org
World Insurance Company
http://www.worldinsco.com
XL Health
http://www.xlhealth.com
Yale University Health Services
http://www.yale.edu/yuhs/menu.html
Zurich North America
http://www.zurichus.com/
Courtesy of: HBMA http://www.hbma.org/news/commercial-payor-resources/health-insurance-plan-links
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