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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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Presentation Transcript
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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