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

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Private payers blue cross blue shield

Private Payers/Blue Cross & Blue Shield

OT 232

Ch 9

OT 232 Ch 9, #3


Interpreting compensation billing guidelines

Interpreting Compensation & Billing Guidelines

  • Contracts should state how allowed amounts are determined

    • Usually a percentage of MPFS or a discounted fee-for-service arrangement

      • 125% of MPFS

        • Medicare pays $100, they allow $125

  • Compiling Billing Data

    • Practices usually bill at normal fee schedule and then adjust so they can keep track of how much is lost

      • Don’t send statement to patient until adjudicated

OT 232 Ch 9, #3


Interpreting compensation billing guidelines cont d

Interpreting Compensation & Billing Guidelines (cont’d.)

  • Getting Billing Information

    • Getting plans to ‘share’ info used to be more difficult

    • Largest private payers were sued for unfair business practices

    • Settlement resolutions, page 313

  • Billing for No-Shows

    • Determined in contract and financial policy

OT 232 Ch 9, #3


Interpreting compensation billing guidelines cont d1

Interpreting Compensation & Billing Guidelines (cont’d)

  • Collecting Copayments

    • They can vary

      • Flat amount vs. rate based on

        • Service provided

        • Procedure performed

        • Multiple visits in a day

        • Secondary’s copay?

      • Two methods

        • Copay is subtracted from fee

        • Fee is reduced by copay

OT 232 Ch 9, #3


Interpreting compensation billing guidelines cont d2

Interpreting Compensation & Billing Guidelines (cont’d.)

  • Avoiding Silent PPOs

    • Provider & payer form a PPO contract, then the payer ‘leases’/shares contract info with a smaller payer so their members can take advantage of the discounted rates also.

    • Provider will get more patients

    • Illegal in some states, but not all, so look for wording in contract

OT 232 Ch 9, #3


Interpreting compensation billing guidelines cont d3

Interpreting Compensation & Billing Guidelines (cont’d.)

  • Billing Surgical Procedures

    • Preauthorization/precertification required for elective surgery

    • Emergency surgeries usually approved within a specific time period

    • Utilization Review Organization (URO)

      • Service hired by a 3rd party payer to review major treatment plans submitted for preauthorization

OT 232 Ch 9, #3


Private payer billing management claim completion

Private Payer Billing Management & Claim Completion

  • Plan Summary Grid

    • Cheat sheet for provider for each payer dealt with

    • Lists specifics of contract

      • Major code bundles

      • Global periods

      • Coding guidelines

      • Documentation requirements

OT 232 Ch 9, #4


Private payer billing management claim completion cont d

Private Payer Billing Management & Claim Completion (cont’d.)

  • Medical Billing Process

    • Steps 1 – 4?

      • Covered!

    • Step 5 – Review Coding Compliance

      • Double, triple check

        • Current?

        • Properly linked and documented?

    • Step 6 – Check Billing Compliance

      • Using plan summary grid, make sure everything’s correct for that particular payer

    • Step 7 – Prepare and Transmit Claims

      • 837 vs. 1500

  • Communications with Payers

OT 232 Ch 9, #4


Capitation management

Capitation Management

  • Patient Eligibility

    • Monthly enrollment list is sent with payment every month

    • Important to always verify

  • Referral requirements

    • Required to stay in-network?

  • Encounter Reports and Claim Write-Offs

    • Simple form vs. regular report?

    • Charges for services are written off

  • Billing for Excluded Service

    • Refer to plan’s summary grid for instructions on handle billing for services not covered by the cap rate

OT 232 Ch 9, #4


Private payer billing management claim completion1

Private Payer Billing Management & Claim Completion

  • Plan Summary Grid

    • Cheat sheet for provider for each payer dealt with

    • Lists specifics of contract

      • Major code bundles

      • Global periods

      • Coding guidelines

      • Documentation requirements

OT 232 Ch 9, #4


Private payer billing management claim completion cont d1

Private Payer Billing Management & Claim Completion (cont’d.)

  • Medical Billing Process

    • Steps 1 – 4?

      • Covered!

    • Step 5 – Review Coding Compliance

      • Double, triple check

        • Current?

        • Properly linked and documented?

    • Step 6 – Check Billing Compliance

      • Using plan summary grid, make sure everything’s correct for that particular payer

    • Step 7 – Prepare and Transmit Claims

      • 837 vs. 1500

  • Communications with Payers

OT 232 Ch 9, #4


Capitation management1

Capitation Management

  • Patient Eligibility

    • Monthly enrollment list is sent with payment every month

    • Important to always verify

  • Referral requirements

    • Required to stay in-network?

  • Encounter Reports and Claim Write-Offs

    • Simple form vs. regular report?

    • Charges for services are written off

  • Billing for Excluded Service

    • Refer to plan’s summary grid for instructions on handle billing for services not covered by the cap rate

OT 232 Ch 9, #4


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