When we talk about matters pertaining to your client’s insurance, you have probably heard the terms “in-network” and “out-of-network” care thrown around quite a bit by different healthcare provider including midwives. But what do these terms actually mean, and more importantly what do they mean for you as a midwife? How will these affect your practice and you be able to apply these terms to your midwifery practice?
What does in-network mean?
In-network refers to a midwives that has direct contract with the health insurance plan to provide health care services to its plan members at a pre-negotiated rate. Because of this relationship, clients pay a lower cost-sharing when they receive services from an in-network midwife.
What does out-of-network mean?
Out-of-network refers to midwives who does not have a contract with the health insurance plan. If a client use an out-of-network provider, health care services could cost more since midwives don’t have a pre-negotiated rate with the client’s health plan. Or, depending on the health plan, the health care services may not be covered at all.
Depending on the coverage the client have purchased, the plan has established deals with a wide range of midwives and other specialists. These are the health care providers that the insurance company considers in your client’s “network.” The insurer has identified a group of providers who are “in-network” and has contracted with these providers on the client’s behalf to get services at “discounted” rates. The primary advantage of using an in-network provider is that your client receive this negotiated or discounted rate for your services, and the insurance provider generally picks up a larger portion of the bill than with an out-of-network provider.
This means that as a midwife, once you’re in an agreement with the insurance company to accept your client’s plans and contracted rate as payment for your full services. This contracted rate that was negotiated by your client and its insurance company includes both the insurer’s share of the cost, and the part that your client will be responsible for paying. The part that your client’s responsibility for paying may be in the form of a co-payment, co-insurance or deductible depending on their negotiation.
Simply speaking, as a midwife, when you accepts your client’s health insurance plan we say you’re in network. You will also be called as “participating providers”. When you don’t take your client’s plan, we say you’re out of network. The two main differences between them are cost and whether the plan helps you receive enough value for the care you provide as out-of-network provider.
Healthcare is an important aspect aspects of our daily lives. As a healthcare provider, we are expected to give the best services to our clients and in order for our practice to keep on growing we must receive proper compensation out of that service. Remind your clients that they can avoid unexpected medical bills by knowing how their plan works. Certain choices they make can affect what they'll pay out-of-pocket. Know the difference between in-network and out-of-network care to help them save on health care expenses.
Outreach & Education. CMS.gov Centers for Medicare & Medicaid Services Health Insurance. (n.d.). Retrieved May 13, 2022, from https://marketplace.cms.gov/outreach-and-education
Accurate diagnosis can have a significant impact on the midwifery practice's claim for billing. It is evident to us that coding and billing are among the most crucial elements in every midwifery clinic. The accuracy within each of them is essential to ensure the safety of patients, quick payments and effective operations.
Historically speaking midwives, other health care providers and payers were on the same page' with regard to fee-for-service reimbursements. Midwives performed a task and the they earned the payment. Simple and straightforward. However, with reforms in healthcare is the requirement for health care professionals to be precise and thorough in the diagnosis codes they use. The shift to pay-for-performance (P4P) programs, originally initiated by the CMS, but increasingly adopted by private payers, demands this accuracy. Along with offering incentives to Midwives for providing quality care, there are now penalties for midwives and other health care professionals who may not be offering patient care of acceptable quality. With this reform, accurate diagnosis became a top priority in order for midwives to claim bills accurately, here’s the reasons why.
Accuracy Was Always an Issue
While accurately recording diagnosis codes has always been important, until P4P programs, many payers accepted marginally thorough supporting information to approve claims and pay providers. The new emphasis on claims clarity often proves to be challenging for midwives and billing staff, particularly for those providers not in the habit of submitting fully documented reimbursement claims.
In the past, claims with faulty diagnosis codes typically were denied. Yet, some insufficiently explained claim submissions slipped through and were approved. If payer claim reviewers were hurried into claim examinations, it was always possible that some submissions that could have had payers ‘scratching their heads’ were approved.
However, most of the diagnosis coding rules have changed. Accuracy, always a factor, has become the primary component of claims approval. Along with approved/rejected decisions, medical providers now face quality care issues, requiring further justification and explanation to eliminate payer confusion.
Proper Diagnosis Critical for Payment
Some midwives and billing personnel seem forgetful that Medicare Advantage plans pay, in part, as a function of the number and severity of sickness in the total population of patients. CMS calculates variable per month payments based on the levels of the ‘sick’ population. Some private payers are endorsing this approach, demanding that physician diagnosis coding ‘fits’ the matrix.
While some midwives during the fee-for-service era always went the extra mile to fully explain their diagnostic coding and process, many other providers, often because of billing staff time constraints, neglected to thoroughly document their diagnosis procedures. However, providers now risk facing claim denials with P4P programs if payer review staff is unsure that the doctor performed diagnostic services that were necessary to design a treatment plan.
Accurate and thorough coding for chronic conditions is another prime area of payer scrutiny. ICD-9 guidelines require providers to use these codes ‘as often as applicable’ when treating chronic conditions. P4P quality care evaluation depends on proper use of these codes. The penalty consequences of taking coding ‘shortcuts’ can result in lower income for the midwife.
These are some of the reasons that using accurate diagnosis codes are critical for maximum claim approvals and CMS decisions that physician care qualifies as meeting quality guidelines. The strong focus on procedural diagnostic coding accuracy is here—possibly affecting your compliance and income levels.
Accurate diagnosis coding, backed up by thorough documentation regarding the necessity of diagnostic procedures, is no longer a payer ‘luxury.’ Accuracy and clarity are now a necessity for all physicians. Achieving this result typically demands some combination of the following actions.
Midwives and other healthcare practices using these tips should remain in HIPAA, CMS and P4P compliance, maintain or increase revenue and create evidence of delivering quality care to all patients. Properly using diagnosis codes and supporting your diagnostic procedures with valid documentation will achieve these results.
Diagnosis coding has taken center stage in medical billing. Coronis. (n.d.). Retrieved September 29, 2022, from https://www.coronishealth.com/blog/diagnosis-coding-has-taken-center-stage-in-medical-billing/
Insurance fraud is any act made to deceive an insurance procedure. It occurs when a claimant attempts to obtain some benefit or advantage they are not entitled to, or when an insurer knowingly denies some benefit that is due. It is also a deliberate deception perpetrated against or by an insurance company or agent for the purpose of financial gain. Fraud may be committed at different points by applicants, policyholders, third-party claimants, or professionals who provide services to claimants. Insurance agents and company employees may also commit insurance fraud. Common frauds include “padding,” or inflating claims; misrepresenting facts on an insurance application; submitting claims for injuries or damage that never occurred; and staging accidents.
People who commit insurance fraud include:
Inside the healthcare industry lies good opportunity for insurance fraud as well. Insurance fraud causes tens of billions of dollars in losses each year. It can raise health insurance premiums, expose you to unnecessary medical procedures, and increase taxes. If you’re in the healthcare industry, you must learn to identify what are the common types of healthcare and insurance fraud.
Common types of healthcare and insurance fraud:
1. Fraud Committed by Medical Providers
How to Prevent Insurance Fraud?
The Affordable Care Act of 2010 included fraud-fighting efforts, such as allowing the U.S. Department of Health and Human Services (HHS) to exclude providers who lie on their applications from enrolling in Medicare and Medicaid and the Improper Payments Elimination and Recovery Act, which requires agencies to conduct recovery audits for programs every three years and develop corrective action plans for preventing future fraud and waste.
Other efforts included:
Additionally, in 2012, HHS and the Department of Justice formed the National Fraud Prevention Partnership to combat health care fraud. The group also consists of private and public groups such as health care companies and their organizations, the National Association of Insurance Commissioners, the National Insurance Crime Bureau and the National Health Care Anti-Fraud Association. The groups will share information on claims from Medicare, Medicaid. and private insurance to be administered by a third-
Fraudulent acts have no escape with the law. Whether you’re a healthcare provider trying to slip away money from your clients, or a client who doesn’t one to compensate the services provided to you. Either way, one must be vigilant enough to take part in protecting his/her right and preventing these things to happen. Keep all your records intact and avoid providing your information to anyone asking for it. Always verify, verify, verify!
Background on: Insurance fraud. III. (n.d.). Retrieved June 18, 2022, from https://www.iii.org/article/background-on-insurance-fraud
Through the years, the field of midwifery as a profession has been the subject of a variety of misconceptions that can go as far as the idea of comparing midwives to quacks. Even today, the job of a midwife can be misinterpreted as simply helping births. Often times, midwives experience misconception about the true quality of service they provide, as it is not only vital for all women and newborns to access care – it is critical that this care is of a sufficient quality to provide a safe and positive childbirth experience, and that it is provided with respect and dignity.
Midwives should be recognized for the excellent the services they provide. It's not a flimsy hoax. There are a few reasons to believe it;
Ways To Increase Awareness
Midwifery is proficient, educated, and compassionate care for childbearing women, newborn babies, and families throughout the pre-pregnancy, pregnancy, childbirth, postpartum, and the early weeks of life. Indeed, midwives are valuable sector of the society and that they need to receive the recognition they deserve.
Barker, J. (2021, February 13). Midwives do not get the recognition they deserve! Blog About Midwives & Doulas. Retrieved September 30, 2022, from https://www.fruitfulwombs.com/midwives-do-not-get-the-recognition-they-deserve/#:~:text=The%20Pros%20For%20Midwifery%3A&text=Quality%20midwifery%20care%20is%20essential,interchangeable%20with%20women%2Dcentered%20care.
The implementation of Affordable Care Act (ACA) has greatly influenced the healthcare industry across United States. Study shows that ACA has reduced the number of uninsured people to historically low levels and helped more people access health care services, especially low-income people and people of color. However, the law’s effects on the cost and quality of health care services are difficult to discern given the complexity of our health system.
Since its passage, midwives gained opportunities to provide better maternal health access to mothers as the ACA helped to improve the quality of coverage for pregnant and birthing people by requiring individual and small group plans, as well as Medicaid expansion plans, to cover maternity and newborn care.
What is Affordable Care Act?
Signed into law on March 23, 2010, the Affordable Care Act (ACA) contains numerous provisions impacting a wide range of health care related issues. The overarching goals of the legislation were to increase the number of people with insurance coverage, improve the design of existing policies, and increase the quality of care provided in the U.S., all while taking significant steps to control costs.
Key issues for midwives include:
Under the law, all individual and small employer insurance plans, including those you get through the Marketplace, must cover maternity and newborn care -- before and after your baby is born.* In the past, most plans sold outside your job didn’t offer much maternity coverage. Some didn't cover it at all.
The ACA doesn't spell out all of the specific benefits that must be covered while you're pregnant and after the baby is born. But many preventive care services must be covered without extra out-of-pocket costs, like co-pays, co-insurance, or deductibles. For mothers, that includes preventive services for preconception and prenatal care and well-baby check-ups plus comprehensive lactation support, counseling, and breastfeeding equipment. Listed below are the codes included in the Affordable Care Act (ACA) that midwives can bill as they provide services.
2. GONORRHEA SCREENING LAB TEST*
3. HIV SCREENING LAB TEST*
4. SYPHILIS SCREENING LAB TEST*
5. BEHAVIORAL COUNSELING TO PREVENT SEXUALLY TRANSMITTED INFECTIONS(If the patient has sign, symptom, or has been exposed to an infection, use appropriate ICD-10 code and 99201–99215)
6. CONTRACEPTIVE COUNSELING(If the patient has a side effect from current method or menstrual irregularity, use ICD-10 code for sign or symptom and 99201–99215. When a patient presents with a problem, it is not appropriate to report a preventive CPT code)
7. WELL WOMAN VISIT(Some payers expect that many of these ACA preventive services—counseling, screening, and immunizations—occur during the annual preventive exam and may not reimburse separately for these on the same day or at subsequent visits.)
8. HUMAN PAPILLOMAVIRUS (HPV) VACCINATIONS
(If not administered during an annual wellness exam, some payers will also reimburse for an office visit)
9. HPV DNA LAB TESTING
10. HEPATITIS (Hep) A IMMUNIZATION (If not administered during an annual wellness exam, some payers will also reimburse for an office visit)
11. HEPATITIS (Hep) B IMMUNIZATION I(If not administered during an annual wellness exam, some payers will also reimburse for an office visit.)
12. Sexually transmitted infection prevention counseling
Adviser, C. S. S., Seeberger, C., Adviser, S., Director, M. C. A., Coleman, M., Director, A., Shepherd Director, M., Shepherd, M., Director, Director, E. L. A., Lofgren, E., Gordon Director, P., Gordon, P., Director, J. P. S., Parshall, J., Director, S., Williamson, H., Taylor, J., Tausanovitch, A., … Conner, A. (2022, June 9). Building on the ACA: Administrative actions to improve maternal health. Center for American Progress. Retrieved September 28, 2022, from https://www.americanprogress.org/article/building-aca-administrative-actions-improve-maternal-health/
Affordable care act (ACA) - glossary. Glossary | HealthCare.gov. (n.d.). Retrieved September 28, 2022, from https://www.healthcare.gov/glossary/affordable-care-act/
Lamboley, L. (2022, September 19). List of Aca Preventive Services and CPT codes [Prevounce Quick Guide]. Prevounce Blog. Retrieved September 28, 2022, from https://blog.prevounce.com/list-of-aca-preventive-services-and-cpt-codes-prevounce-quick-guide
List of Aca Preventive Services and CPT Codes - Std Tac. (n.d.). Retrieved September 28, 2022, from http://stdtac.org/wp-content/uploads/2014/06/List-of-ACA-Preventative-Services-and-CPT-Codes-_STDTAC.pdf
Regulations are used to safeguard and enhance the lives of businesses, individuals as well as the environment, and to help boost economic growth. In order to fully protect everyone’s interest within certain organization, regulations must be updated from time to time if there’s a need. Medical billing may indirectly impact the healthcare industry, but it is important to maintain order and organization in the industry.
To become an effective biller, one must understand the different billing regulations, private and public insurance plan policies. Here are new billing regulations for 2022 every biller as well as customers must be aware of.
1. No Surprises Act Comes into Effect on January 01, 2022
Beginning January 1, 2022, midwives and other health care providers will be required by law to give uninsured and self-pay patients a good faith estimate of costs for services that they offer, when scheduling care or when the patient requests an estimate.
This new requirement was finalized in regulations issued October 7, 2021. The regulations implement part of the “No Surprises Act,” enacted in December 2020 as part of a broad package of COVID- and spending-related legislation. The act aims to reduce the likelihood that patients may receive a “surprise” medical bill by requiring that providers inform patients of an expected charge for a service before the service is provided. The government will also soon issue regulations requiring midwives and other healthcare professionals to give good faith estimates to commercial or government insurers, when the patient has insurance and plans to use it.
Midwives working in group practices or larger organizational settings and facilities will likely receive direction from their compliance department or lawyers on how to satisfy this new requirement.
Its implementation means that patients can no longer be held accountable for emergency services from out-of-network providers or out-of-network hospital services (including ambulance services and emergency room physicians). It also implies that patients should not be liable for ‘balance billing’ by an in-network healthcare facility for services received from out-of-network providers (such as radiologists, anesthesiologists, pathologists, or neonatologists).
2. CMS Announces Lower Medicare PFS conversion factor
The CY 2022 conversion factor will be $33.59, a decrease of $1.30 over the CY 2021 conversion factor. But it’s not just this cut that will impact medical practice revenues in 2022. It’s estimated that the combined effect of the PFS cuts since 2021, as well as the 4 percent Statutory Pay-As-You-Go (PAYGO) cut and the 2 percent cut for Medicare sequestration, will lower medical practice revenues by 10 percent.
3. Modifications in POS codes for Telehealth
The point of service (POS) codes for telehealth will see two main changes. POS 02 has been revised for cases when the telehealth consult occurs outside the patient’s home. POS 10 has been introduced to cover telehealth consults while the patient is home.
4. Split (or Shared) E/M Visits
CMS has stipulated that in 2022 the provider who handles the substantial portion of the visit (which could be on any of the three components – the time spent on history, exam, or medical decision making), or more than half of the total time spent, would bill for the visit.
5. Direct Billing of Physician Assistant (PA) Services
Beginning January 01, 2022, PAs can bill Medicare directly for their services and reassign payment for their services. Currently, payments for services delivered by PAs are made by Medicare to their employers.
These are just a handful of medical coding and billing changes you can expect in the coming year. Keeping track of these changes and training your staff will be crucial to ensuring that your medical practice revenues don’t dip in 2022. If you’re wondering how you’ll stay on top of these medical billing changes in your medical practice, now is an excellent time to partner with an experienced medical billing service.
American Psychological Association. (2021, December 10). New billing disclosure requirements take effect in 2022. https://www.apaservices.org. Retrieved September 27, 2022, from https://www.apaservices.org/practice/legal/managed/billing-disclosure-requirements
Blog, P. F. (2021, December 27). 5 top medical billing changes in 2022. Medical billing and collections as low as 1.99%. Retrieved September 27, 2022, from https://practiceforces.com/blog/medical-billing-changes-in-2022/
Audits can be a painful part of the daily practice routine even for the best chiropractic teams. An oversight or omission could lead to massive fines and penalties that could have a significant impact on your business. Additionally, all claims your business submits are subject to rigorous prepayment reviews or post-payment audits.
Protecting yourself requires ensuring the best practices and looking at things from the other viewpoint. Here are some suggestions that can make a significant difference.
1. Know How Auditors Operate
Audit provides the framework to improve the quality of patient care in a collaborative and systematic way. Through Audit we can identify emerging trends, which enables us to identify risks and implement actions before it becomes a bigger issue.
If you know how auditors operate, you will know the key aspects where to improve your billing practices. Ensure to learn from audits and review data thoroughly. Scrutinize data to ensure gaining all that you can from it and move forward making the necessary changes to support best practice
Using this document is your way of seeing inside the audit process and knowing which practice areas are scrutinized. You’ll then be better equipped to ensure that your documentation makes the grade. You can also review the Medicare Program Integrity Manual for more insight into how auditors work.
2. Always Prepare Accurate Documentation
Accuracy encompasses all forms of information oversight: patient identification, amendments and corrections to records, validation of author, plus auditing for document validity before sending out as part of a claim for payment. Knowing that multiple systems will probably be involved in an audit, all data should be documented, including meaningful use, reports generated by the practice’s EHR system, and other evidence supporting medical decisions.
Procedures that are more likely to be scrutinized are sleep studies, outpatient physical therapy and MRI’s, which the Office of Inspector General (OIG) believes may be overused and are among the OIG/RAC targets requiring careful documentation.
3. Review Key Qualifiers
Every claim should clear internal quality checks before submission. Be sure the service you provided to the patient:
4. Use Correct Midwifery Billing Software
The right computer program can catch errors that are the result of human error. In addition, there is a plethora of available software that practices can use to streamline their documentation and reduce audit risks across the board.
Many of these solutions are cloud-based, which is a great advantage. It means you’re always running the most up-to-date software to help keep your compliance current and that your valuable documentation data is being continuously backed up off-site.
5. Review Audit Risk to Lower Reimbursement
As more prepayment and health plan audits emerge in the healthcare landscape, hospitals can use them as new opportunities for cost savings in audit management, record request responsiveness, and health plan collaboration. Many providers have found some principles ways to use audit storms to strengthen operational processes and mitigate reimbursement losses.
6. Plan for the Worst-case Scenario
As the saying goes, “prepare for the worst and hope for the best.” Most audits are triggered due to a history of non-compliance or related past problems; however, more practices are being randomly audited, even with no apparent violations or errors.
7. Be proactive
Hope alone will not prevent an audit nor ensure that your practice passes one. If your practice is audited at random, having all of your documentation complete, accurate and fully compliant is the only way to be confident that your practice won’t be caught off guard and that if audited, the results will be favorable.
8. Experienced Medical Billing Service Provider Part of Your Team
As Midwives, your biggest priority is caring for your clients, and getting you compensated for your hard work is ours. Midwives need every advantage when navigating the complex world of insurance claims. Our role during this process is to connect your practice and insurance seamlessly. We act as the back office that manages administrative duties so that you can focus on your passions, mamas, and their babies.
We provide straightforward, affordable solutions that streamline the insurance process and get you paid. Our office employs certified coders, medical compliance officers, and practice management professionals to implement protocols that bring you the most valuable payout. We are certified in HIPAA requirements, ethics, and practice management so you can entrust us with your clients' information
Documentation tips that reduce audit risks. ChiroHealthUSA. (n.d.). Retrieved September 28, 2022, from https://www.chirohealthusa.com/member-providers/documentation-tips-that-reduce-audit-risks/
5 documentation tips to reduce RAC audit risk. Coronis. (n.d.). Retrieved September 28, 2022, from https://www.coronishealth.com/blog/5-documentation-tips-to-reduce-rac-audit-risk/
Referral in the most basic understanding is a written order from the primary care specialist to see another specialist and get the patient certain medical services. In many Health Maintenance Organizations (HMOs), the patients need to get a referral before they can get medical care from anyone except their primary care doctor. If they don’t get a referral first, the plan may not pay for your services. Referrals are required by some insurance providers to ensure that the patient will receive accurate service from the right people.
Patient referral is a common and important medical practice. Sometimes, a patient’s condition is outside a physician’s area of expertise, and the physician needs to refer the patient to a specialist who is more knowledgeable about or experienced in treating the condition. In the United States, for example, doctors refer one in every three patients to a specialist each year. Every referral is meant to ensure the best outcome for the patient.
How to Get a Physician Referral
Historically, physicians have known that in reporting a consultation service, the three R’s must be documented: Request, Render, and Report. Starting in 2006, CPT requirements have included one more R requirement: a Reason. There must be a request for consulting services from another physician or health care provider, the suspected or known diagnosis requires determination by a specialist who renders his / her opinion, the referring physician and consultant specifies a reason for the consultation, the treatment is undetermined or may be known, and a written report to the requesting physician or referring source reiterating the reason for consultation plus the findings and opinions must be forwarded by the consultant. In most cases, a consultation is a one – time visit.
A New Patient Referral usually has an identified problem which requires a specialist to provide care, and does not require that a written report be sent to the requesting physician or health care provider.
The policy changes or clarifications also state that a transfer of care occurs when a physician requests another doctor to assume the care of the patient. Ongoing management of the patient by the consultant physician cannot be reported using a consultation service code. Therefore, a referral for evaluation and management (E/M) cannot be considered a consultation because there has been a transfer of care. There also has been concern regarding language that the consulting physician must document the request and reason for the consultation in the patient’s medical record. Without that documentation, the CPT code for a consultation could not be used.
However, according to the E/M documentation guidelines, the consulting physician is not required to confirm that the requesting physician documents his / her request. The documentation criteria for a consultation service requires that the requesting physician and consulting physician both document the request for consultation in their medical records, but each physician is required to keep their own accurate records and code accordingly. In the revised Medicare Claims Processing Manual, the section which discusses consultation followed by treatment, there are also rules governing those occasions when it may be necessary for the consulting physician to assume ongoing care of the patient. It should be emphasized that the above guidelines differentiating a Consultation from a New Patient Referral apply primarily to Medicare patients. Currently it appears that non – Medicare payers have not yet implemented these regulations.
Understanding each of these processes and how to determine what is required by the insurance is key to avoiding lost revenue and negatively impacting patients financially. Having knowledgeable support staff in the area of preservice is crucial to any organization. The return on investment in insurance reimbursement and patient experience alone is worth the cost of having this expertise at your institution.
References and Useful Links
Lori. (n.d.). New Patient Consultation and new patient referral – what is the difference. Medicare Payment, Reimbursement, CPT code, ICD, Denial Guidelines. Retrieved August 6, 2022, from https://medicarepaymentandreimbursement.com/2010/10/new-patient-consultation-and-new.html
PatientPop. (2022, April 20). When and how to refer patients to a fellow physician. PatientPop. Retrieved August 6, 2022, from https://www.patientpop.com/blog/physician-to-physician-referrals-reducing-liability-and-improving-patient-care/
The Center of Medicaid and Medicare Services (CMS) form 1500 must be used to bill SFHP for medical services. The form is used by Physicians and Allied Health Professionals to submit claims for medical services. All items must be completed unless otherwise noted in these instructions. A CMS 1500 with field descriptions and instructions is included in the link below: https://www.sfhp.org/wp-content/files/providers/forms/Instructions_for_CMS_1500_Claim_Form.pdf
Billing plays a vital role to keep your business running. It determines your capacity as a business owner to make your cash flow intact avoiding the business to collapse. While you continue to create greater impact, your business will continue to prosper if you know how to manage your finances carefully. From record keeping, cash in and cash out, invoice, giving statement and collection, billing takes place. It requires enough expertise to keep tracking all of these because inaccurate billing can cause serious problems. In the absence of accurate and reliable billing, major distractions to expected liquidity can ruin reinvestment plans, and in extreme cases put operations at risk.
Owning and billing for your own midwifery practice helps you and your practice in numerous ways. It gives you the opportunity to offer outstanding midwifery care, exactly how you envisioned your practice to be. It provides you the freedom and flexibility to manage your finances and cash flow.
However, like most of us desire to simply manage the in and out of our practices’ revenue and profitability, reality hits that this is beyond what we envisioned. In reality, it is not easy to crawl down tracking all the records, keeping all the collections, updating codes and description, managing finances, and all other aspects that are involved in billing and coding. Not to mention you being busy as the expert of your own practice, your business will cripple if you can’t manage these factors properly. Time will surely come that you will question yourself how you may be able to get out of that duty. To prevent that from happening, you should know how to assess your business’ needs. Are you capable of doing billing tasks on your own? Or is it time to ask for help from the experts? Here’s what you need to do to assess your practice further.
Assess Your Practice
To find out what the best choice is for your business, ask yourself these questions about your billing process, staff, physical space, and plans for the future:
Assessing your own practice by answering this set of questions will help you understand the needs of your practice. If you answered YES to most of the questions, then outsourcing will be good for you. Outsourcing by means of hiring medical billers and bringing in their expertise to your practice. However, if you answered NO to most of the questions stated, then keeping your billing operations within your practice is the best choice for you. There are a lot of great benefits if you choose to hire an expert biller like Midwives Advantage but choosing to keep your billing procedures in-house is not a bad idea either. You have to simply weigh the needs of your practice.
To hire or not to hire billing service. (n.d.). Retrieved August 5, 2022, from https://www.kareo.com/documents/to-hire-or-not-to-hire-billing-service.pdf
Healthcare system in the United States is very complex. Before the patient decides to see a specialist, the first question that needs to be answered is if he/she has health insurance. There’s a huge variety of group health insurance plans offered through employers, but the system also includes Medicare, Medicaid, the Veterans Health Administration system, and individual plans offered through the insurance markets set up by the Affordable Care Act. The kind of insurance that your patient has can directly influence how much your patient pays for healthcare and what doctors or specialists he/she is permitted to see. This is why health insurance providers are a lot more complicated than any other type of insurance. Over time it gets more complicated as new laws, regulations, court cases and differing opinions start to add complexity.
To ensure that a client's insurance provider will pay up all the required medication and treatment, doctors and other medical professionals require prior authorization to their clients. Under some medical and prescription drug plans, treatments and medications may need approval from the health insurance provider before you provide care.
Prior authorization is usually required if your client needs a complex treatment or prescription. Coverage will not happen without it. One reason why health insurance providers require this type of document before proceeding with different medical procedures is that a less expensive treatment option may be sufficient rather than simply defaulting to the most expensive option. To make sure that reimbursement will not be denied and that you will receive proper compensation, this document must be secured prior to giving your client the required procedure.
How to Get Prior Authorization?
If you’re in-network to your patient’s insurance coverage, then you have to prepare the necessary documents for your patient. Prior-authorization procedures are different from every insurance provider.
Submission of Prior Authorization Request
You submit your pre-authorization request by mail or fax. Many authorization companies provide Prior Authorization Request Form (both offline and online) to submit written pre-authorization. Every insurance company has its own requirements for pre-authorization requests. However, you should include the following information in all types of requests.
How Long Do Prior Authorizations Take?
The process of obtaining and maintaining prior authorizations is vital to the success of any medical practice. Overall, the prior authorization process impacts almost every aspect of the revenue cycle and operations of your medical practice.
HOW TO REQUEST A GAP EXCEPTION/ PRIOR AUTHORIZATION FOR OUT OF NETWORK CARE How to request a gap exception/ prior authorization for out of network ... (n.d.). Retrieved August 6, 2022, from https://favoredmedicalbilling.com/forms/GAP_Request_Guide_for_Midwives_and_Birth_Centers.pdf
Lower burden with outsource prior authorization: Drcatalyst. English. (n.d.). Retrieved August 6, 2022, from https://www.drcatalyst.com/importance-of-prior-authorization
Prior authorization. Santa Clara Family Health Plan. (n.d.). Retrieved August 6, 2022, from https://www.scfhp.com/for-providers/provider-resources/prior-authorization/
Clements, J. (2022, July 14). What is prior authorization? when is it needed and not? Outsource Strategies International. Retrieved August 6, 2022, from https://www.outsourcestrategies.com/blog/what-is-prior-authorization-when-is-it-needed-and-not/