Billing and Claim Billing and Claim Submission Boot Camp Submission Boot Camp Beverly Remm Beverly Remm

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1 Billing and Claim Submission Boot Camp Presented by: Beverly Remm Orion Healthcare Technology Billing and Claim Submission Boot Camp Presented by: Beverly Remm Orion Healthcare Technology The presentation will begin shortly. Using GoToWebinar Presented By ü Control Panel ü Asking Questions ü PowerPoint Slides ü Audio (phone preferred) ü webinars ü webinars Obtaining CE Credit Presenter The education delivered in this webinar is FREE to all professionals. 1 CE is FREE to NAADAC members and AccuCare subscribers who attend this webinar. Non-members of NAADAC or non-subscribers of AccuCare receive 1 CE for $15. If you wish to receive CE credit, you MUST complete and pass the CE Quiz that is located at: (look for name of webinar) A CE certificate will be ed to you within 21 days of submitting the quiz and payment (if applicable). Successfully passing the CE Quiz is the ONLY way to receive a CE certificate. Beverly Remm Director of Billing at Orion Healthcare Technology 1

2 Webinar Topics Billing Boot Camp Getting Your Billing in Shape NPI number Provider enrollment and insurance contracts Setting up a menu of service and fee schedules Routine procedures billing to insurance companies ICD-10 Current Regulations Step by Step list for just getting started Webinar Goals Whether you are a New provider or business owner Never have billed before Previous billed insurance Currently billing National Provider Identifier NPI This presentation should Provide information in ways you can improve your current billing process Inform you how and where to start to have a successful billing department Update you on current billing guidelines and upcoming changes. National Provider Identifier Number (NPI) Mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Issued by Center for Medicaid and Medicare (CMS) A Unique 10 digit Identifier for healthcare providers (facilities and individuals) Who Should Apply for an NPI number? Who Should Apply for a Number? Licensed individuals and entities that provide health care services Providers that are going to bill for health care services Any health care provider that has a taxpayer identifying number. Who Should NOT Apply for a Number? Groups, partnerships, or corporations. Physicians who have opted out of government medical programs. 2

3 How to Apply for an NPI number Website: - Online application or download forms - Have your application information ready Provider Enrollment and Insurance Contracts Receive your NPI number typically in 1-2 weeks Call NPPES at for assistance Provider Enrollment Process Every insurance company plan will have different requirements and process for Provider Enrollment. Application forms Copies of documentation (example: W-9, license certification, etc.) Signed Provider Agreements Provider Enrollment Assistance Many insurance companies will have documents and instructions online. Listing requirements Steps for enrolling Billing services can assist with process Completing forms Gathering the required documents Follow up on application status Provider Enrollment Completed Once you have become in-network or contracting a provider with an insurance company your next step is to become familiar with guidelines and billing requirements. Billable and Payable Service Codes Current Fee Schedules Specialty Billing guidelines Claim Submission and timely filing limitations Provider Enrollment Completed Based on your provider enrollment contract there are some standard questions that you should review in your contract. How can I verify client eligibility? Do I need authorizations for services rendered? What are the claims submission guidelines? 3

4 Determining your practice s rates and financial policies Center for Medicare and Medicaid (CMS) Fee Schedule What is a fee schedule? A fee schedule is a complete listing of fees used by health plans to pay doctors or other providers. The CMS fee schedule is categorized per state & per individual service. The CMS fee schedule is updated annually and the amount for any service will be based on the actual place of service address. The CMS fee schedule can be found at license-agreement.aspx Fee Schedule on the CMS website Searching Instructions 1. Click Accept to agree to the CPT licensing terms 2. Choose the year of the Fee Schedule you would like to view. 3. Select the individual or multiple type of information you would like to view. 1. Pricing Information 2. Payment Policy Indicators 3. Relative Value Units 4. Geographic Practice Cost Index 5. All 4. Select the HCPCS Criteria 1. Single HCPCS Code 2. List of HCPCS Codes 3. Range of HCPCS Codes 5. Select a Carrier/MAC option 1. National Payment Amount 2. Specific Carrier/MAC 3. Specific Locality 4. All Carriers/MACs 6. Enter the HCPCS or CPT code 7. Select the appropriate modifier to view. 1. Global Professional Services Professional Component Procedures which the physician terminated before completion 4. TC Technical Component 5. All Modifiers 8. Click Submit to view the information. Fee Schedule on the CMS website Searching Instructions Why CMS? Medicare typically paves the way for the guidelines and rates that many other insurance companies will use to establish their own fee schedules. It is recommended to add at least 35% to what CMS lists as a reimbursement as your rate of service. Why CMS? (continued) Why charge 35% more than what Medicare will actually reimburse for? Fee Schedules are updated annually. Insurance Companies evaluate provider charges before updating Adjustments can be made to the fee schedule and reimbursements to be closer and comparable to what the providers are charging. 4

5 Questions to ask.. 1. What is the level of difficulty of the service I am providing? 2. The services you provide are such a value to your patients. 3. Look at any ancillary costs you have that help provide services for your patients. 4. Take into consideration any malpractice insurance that is paid. You want to make sure you are making more than what you are paying out. 5. Recognize the diversity of patients that you treat and what they can afford; your rates should be appropriate for all customers. Financial Policy Protecting Your Practice Consider creating a financial policy for your office or practice. A financial policy will outline the rules for patients when it comes to billing and payments. This can help you receive the full compensation that is deserved for your services. The financial policy should include information such as how insurance will be handled, payment options, sliding fee scales, collection procedures, co-pays, etc. Financial Policy Protecting Your Practice Every patient should receive a copy of your financial policy. Patients should sign a financial policy agreement. A financial policy should outline and explain the expectations of your patients when it comes to patient accounts. Anytime you update your policy you need to make your patient aware of any changes and they should sign a new agreement. Financial Policy for Patient s without Insurance The Promissory note is an signed agreement between the provider and the patient. It should explain that the patient is expected to pay for services and explain the actions that will be taken if payment is not made. When treating patients that do not have insurance it is a good idea to have a Promissory Note on file. Out of Network Patient Wavier The waiver will be an agreement between the provider and the patient. Waiver should be used when an insurance company does not pay for out-of-network provider services. Also when an insurance company pays at a lower rate for out of network providers. This will let the patient know that they might be responsible for the charges that are not reimbursed by the insurance company. Rules and Guidelines There are some guidelines that should be followed to make sure that your billing and financial policies are legal and non fraudulent. 1. The same the rate must be charged for same service for all patients. Changing the amount charged for the same service especially when billing to insurance is consider insurance fraud. 2. Do not discount patient balances without validity. 3. Collection policy needs to apply to all clients and customers, unless proper documentation is signed and in the patient s file. 5

6 Discounting Patient Balances There are only two reasons why a provider should waive or discount a patient s deductible that is owed. 1. The Patient has bad debt 2. The Patient has proof of Financial Hardship Documentation of these reasons should be on file in the patients chart and there should be documentation of the patient s acknowledgement of these circumstances. Sliding Fee Scales Sliding Fee scales are used to list adjusted rates for lower income patients. Documentation should be provided to by the patient to show their proof of their income and the limits that they have when it comes to income and expenses. Using the Sliding Fee Scale will allow a provider to legally offer a discount for patients that cannot afford services at the full rate. Billing Methods Pre-Billing Workout These are activities should be done prior to submitting claims for a client. Verify eligibility Client s benefits and coverage Co-pays and Deductibles Obtain authorizations Secure billing information with insurance company Claims address and Electronic Payer Id Billable procedure codes Options for your Billing Process } State Software Programs A software system offered by your State Medicaid to submit provider billing and claim information } Outsource Services A contracted service to track and submit your billing and claims for Medicaid, insurance, etc. } Billing Software System A software application used to track and submit your billing and claims for Medicaid, insurance, etc. State Medicaid Software System: Pros vs. Cons Cons Limited Pros Free software Enter specific information needed by Medicaid information output Duplication of data entry Extra time spent on support needs 6

7 Outsourcing a Billing Service What you should expect from your Billing Service Manage submission of all services to Medicaid Knowledgeable with State and Medicaid guidelines Assist with follow up on denied or unpaid claims Clear understanding of your agency s goals and needs Provide detailed reports for services and claims Work with insurance companies on claims issues to ensure payment on claims Billing Software System What to look for in a Billing Software System HIPAA ready Patient Privacy Regular updates to software for industry compliance Personal and reliable customer support Easy to use Electronic Claims Submission Experience in your specialty and services ICD-10 Diagnosis Codes Changes in Diagnosis Codes Currently scheduled for October 1 st, 2013, the current diagnosis code set, ICD-9, will be replaced with the ICD-10 code set. The format of diagnosis codes will change. The number of diagnosis codes will increase. Codes will be more defined and specific. ICD-10 Deadline Update HHS Secretary has issued a press release announcing a proposed rule that would delay the compliance date for ICD-10 from October 1, 2013 to October 1, Public comments are being reviewed and analyzed, and the Department will issue a final rule as expeditiously as possible. Follow information on the CMS website to stay up to date on any ICD-10 changes or updates ICD10/ What is ICD-10? ICD-10 stands for International Classification of Diseases 10 th Edition ICD is the diagnosis classification system for the use in all US health care treatment settings. ICD-10 was developed by the Center for Disease Control and Prevention 7

8 Two segments of ICD-10 ICD-10 CM (Clinical Modification) ICD-10 CM (Clinical Modification) ICD-10 PCS (Procedural Coding System) Increases diagnosis codes from 13,000 to 68,000 codes. ICD-10-CM is for use in all U.S. health care settings. ICD-10-CM uses 3 to 7 digits instead of the 3 to 5 digits used with ICD-9-CM ICD-10 PCS (Procedural Coding System) Used for inpatient procedure coding, hospital settings only Code set includes facility procedure codes and increases the total content from 11,000 to 87,000 codes. ICD-10 PCS uses 7 alphanumeric digits instead of the 3 or 4 numeric digits used under ICD-9-CM procedure coding. ICD-10 PCS codes are more specific and substantially different from ICD-9-CM procedure coding. ICD-9 vs. ICD-10 ICD-9 produces limited data about patients medical conditions. ICD-9 also produces limited data about hospital inpatient procedures. ICD-9 is over 30 years old, has outdated terms, and is inconsistent with current medical procedures ICD-9 vs. ICD-10 ICD-9 vs. ICD-10 ICD-10 provides more specific information about patients medical conditions. ICD-10 provides details about hospital inpatient procedures. The structure of ICD-9 limits the number of new codes that can be created, and many current ICD-9 categories are full. The structure of ICD-10 is expanded and allows for more codes to be created. The new index gives the ability to use more categories and subcategories. 8

9 ICD-9 vs. ICD-10 ICD digits First digit alpha or numeric Digits 2-5 are numeric ICD digits First digit is alpha; Second digit is numeric Digits 3-7 are alpha or numeric Examples of ICD-10 Codes ICD (Bipolar Disorder, Depressive, Mild) (Cannabis Dependence, Continuous) 837 (Dislocation of ankle) ICD-10 F31.31 (Bipolar Disorder, Current Epsd Mild) F12.20 (Cannabis dependence, uncomplicated) S93.04XA (Dislocation of right ankle joint) Current Insurance and Claim Guidelines What is Version 5010? Version 5010 is the newest set of format standards to communicate electronic health information data. Will include the necessary infrastructure changes in preparation for the ICD-10 codes. The mandated implantation date for Version 5010 was January 1, Who regulates Version 5010? HIPAA (Health Insurance Portability and Accountability Act) Mandated there needs to be specific and national formats for electronic claims and claims-related transactions. Who regulates Version 5010? ANSI ASCx12 (American National Standards Institute Accredited Standards Committee) Responsible for developing and maintaining the standards for the formats for electronic transactions. 9

10 Who regulates Version 5010? CMS (The Center for Medicare and Medicaid) The Center for Medicare & Medicaid Services is responsible for oversight of compliance. Examples of new format and data changes in Version 5010 NPI numbers NPI numbers will be required for all providers and facilities Taxonomy codes Taxonomy code for all providers and facilities will be required and updated Nine digit zip codes Nine-digit zip code must be reported for the Billing Provider and Location of Service address fields. Should review current zip code values they to be sure they are valid nine-digit zip codes. CPT Codes (Current Procedure Terminology) CPT Codes will not be changed or affected ICD-10 will allow for additional coding on CPT codes What is the difference between CPT and ICD? CPT is the Current Procedural Terminology (CPT) code set and is maintained by the American Medical Association. The CPT code set describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures. New editions are released each October. The current version is the CPT CPT coding is similar to ICD-9 and ICD-10 coding, except that it identifies the services rendered rather than the diagnosis on the claim DSM-V The current Diagnostic and Statistical Manual of Mental Disorders (DSM) is in the 4 th Edition DSM-V new codes expected release is May DSM-IV codes are not recognized for processing or reimbursement by health plans Paper Claim Forms HCFA-1500 and UB-04 Claim Forms It has been suggested that forms will be updated prior to October 1, 2013 No release date has been given To stay updated on the DSM-V release and information follow the AMA website at 10

11 Submitting Claims Patient information: Name, address, gender, date of birth, diagnosis code Insurance Information: Name, address, gender, date of birth Example of Claim form HCFA 1500 Claim form Outpatient services Business and Provider Information: Name, NPI number, Taxonomy number, address Service Information: procedure code, date of service, charge amount Example of Claim form Ready to Start Billing? UB 04 Claim form Inpatient services Checklist for Billing NPI number Provider Enrollment or Insurance Contracts Determined rates for services Financial policy established for your practice Checklist for Billing Up to date on current procedure codes and diagnosis codes Staff trained to verify client eligibility and obtain authorizations Billing Method in place Outsource billing service In house billing software (claim forms) 11

12 Verify Client Eligibility Why verify Eligibility? Does the client have active coverage? Does the client need to pay you anything at the time of visit? Will the insurance company be able to reimburse you for services? Where should you submit the claims? Verify Client Eligibility How to verify eligibility? Is this client active? Is there coverage for Chemical Substance Abuse or Mental Health? What is the effective date of coverage? What is the patient s deductible? How much of the deductible been met? What is the maximum visits or $ amount for SA or MH services? Does the client have a co-pay? Are authorizations required? Is there already authorization on file? What is the number to call for authorizations? What is the claims address for claims to be sent to? (Even if this is printed on the back of the card it is still important to ask and verify) Steps for Billing Provide services to clients Submit claims Receive reimbursement and remittance from insurance companies. Steps for Billing Track all services and payments Follow up on outstanding balance Follow up with insurance on unpaid or denied claims Billing Cycle Client information Verify Client Eligibility Beverly Remm - Track and Follow up on balances Collect & Receive reimbursement Document Treatment Provide Treatment to Client Feel free to ask questions through the Questions pane. Submit Insurance Claims 12

13 Upcoming Free Webinars Archived Webinars August 22, Providing Effective Opioid Dependence Treatment: Connecting Science with Treatment September 19, Healing the Addicted Brain: Cutting Edge Science and Brain Neurochemistry 2012 Webinar Series ü New webinar monthly! ü Education is free to all professionals. ü CE credit available for purchase. ethics, adolescents, criminal justice, trauma and many more Information and Registration at: or Medication Assisted Recovery: What Every Addiction Professional Needs to Know Building Your Business with SAP/ DOT Screening, Brief Intervention and Referral to Treatment (SBIRT) Billing and Claim Submission Changes Ethics Co-occurring Disorders Test-Taking Strategies Conflict Resolution Clinical Supervision ASAM Placement Criteria DSM-5 Proposed Changes Archived webinars: or CE credit still available! The clinical tools you need. The customer support you deserve. That s why Orion Healthcare Technology is the preferred software vendor of NAADAC. Assessments and Screening Patient Placement Treatment Planning Progress Notes Discharge Summaries Insurance Billing Reporting and Tracking Prevention Tracking For more information: Click: Call: (800) Obtaining CE Credit The education delivered in this webinar is FREE to all professionals. 1 CE is FREE to NAADAC members and AccuCare subscribers who attend this webinar. Non-members of NAADAC or non-subscribers of AccuCare receive 1 CE for $15. If you wish to receive CE credit, you MUST complete and pass the CE Quiz that is located at: (look for name of webinar) A CE certificate will be ed to you within 21 days of submitting the quiz and payment (if applicable). Successfully passing the CE Quiz is the ONLY way to receive a CE certificate. Beverly Remm - Thank You for Participating! 13

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