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

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

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

4. Interpreting Compensation & Billing Guidelines (cont’d) Collecting Copayments –T–They can vary Flat amount vs. rate based on –S–Service provided –P–Procedure performed –M–Multiple visits in a day –S–Secondary’s copay? Two methods –C–Copay is subtracted from fee –F–Fee is reduced by copay 4

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

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

7. Private Payer Billing Management & Claim Completion Plan Summary Grid – Cheat sheet for provider for each payer dealt with – Lists specifics of contract Major code bundles Global periods Coding guidelines Documentation requirements OT 232 Ch 9, #47

8. Private Payer Billing Management & Claim Completion (cont’d.) Medical Billing Process – Steps 1 – 4? Covered! – Step 5 – Review Coding Compliance Double, triple check – Current? – Properly linked and documented? – Step 6 – Check Billing Compliance Using plan summary grid, make sure everything’s correct for that particular payer – Step 7 – Prepare and Transmit Claims 837 vs. 1500 Communications with Payers OT 232 Ch 9, #48

9. Capitation Management Patient Eligibility – Monthly enrollment list is sent with payment every month – Important to always verify Referral requirements – Required to stay in-network? Encounter Reports and Claim Write-Offs – Simple form vs. regular report? – Charges for services are written off Billing for Excluded Service – Refer to plan’s summary grid for instructions on handle billing for services not covered by the cap rate OT 232 Ch 9, #49

10. Private Payer Billing Management & Claim Completion Plan Summary Grid – Cheat sheet for provider for each payer dealt with – Lists specifics of contract Major code bundles Global periods Coding guidelines Documentation requirements OT 232 Ch 9, #410

11. Private Payer Billing Management & Claim Completion (cont’d.) Medical Billing Process – Steps 1 – 4? Covered! – Step 5 – Review Coding Compliance Double, triple check – Current? – Properly linked and documented? – Step 6 – Check Billing Compliance Using plan summary grid, make sure everything’s correct for that particular payer – Step 7 – Prepare and Transmit Claims 837 vs. 1500 Communications with Payers OT 232 Ch 9, #411

12. Capitation Management Patient Eligibility – Monthly enrollment list is sent with payment every month – Important to always verify Referral requirements – Required to stay in-network? Encounter Reports and Claim Write-Offs – Simple form vs. regular report? – Charges for services are written off Billing for Excluded Service – Refer to plan’s summary grid for instructions on handle billing for services not covered by the cap rate OT 232 Ch 9, #412