Biggest Myths In Taking Insurance In Private Practice

Biggest Myths In Insurance In Private Practice


Biggest Myths In Taking Insurance In Private Practice

In this series we share a new exciting topic all about insurance in private practice, but more specifically, the Biggest Myths in Taking Insurance in Private Practice! Billing and insurance expert, Jeremy Zug, and Joe Sanok will be covering the following big myths:


Myth 1: “I can only practice in the state that I live in (state reciprocity)”

Look into the licensure of your state and make sure you are licensed in the state you want to offer services in. Also make sure you’re credentialed in that state according to their insurance company laws. Use Telehealth platform that is HIPAA compliant.

Myth 2: “Credentialing only takes 30-60 days”

Credentialing is a long process. Insurance companies process applications as they receive them. This hardly happens between 30-60 days, but rather between 90-180 days. This is due to the industry growing and also because insurance companies are not concerned with fast-tracking your application.

Myth 3: “I need to be on every insurance to have a successful practice”

When you’re on a number of insurance panels, you’re likely to end up with thousands of dollars in outstanding claims past 120 days. This will stop you from making progress on your revenue goals. Instead, take one insurance and build your practice around that insurance. Then, a year or two later, add another one. Once that’s established, add another one, and so on.

Myth 4: “You don’t get paid as much as an out-of-network provider”

An out-of-network provider is 100% private pay while also being somewhat involved in the insurance world. With out-of-network, you’re able to bill the patient for the entire cost of the session, and have payment go to the patient for the insurance portion. Or, you can bill the insurance, charge the patient for their co-pay, and then collect from the insurance company. Whatever the insurance company doesn’t cover, you can get the patient to pay.

Myth 5: “Insurance is better than private pay”

There is a case for private pay. You don’t have accounts receivables to deal with. You get the cash in hand. Pay roll becomes easier. Private pay allows you the freedom to do some volunteer work and also charge your full fee.


Insurance Terms You Need To Know In Private Practice

In this video, we get to grips with all insurance in private practice terms you absolutely need to know! Here are just a few brief terms we’ll be discussing:

  • Explanation of Benefits (EoB): Document that comes with payment from the insurance company (also explains why the payment was denied)
  • Electronic Remittance Advice (ERA): Same as an EoB, except the electronic version
  • Electronic Health Record (EHR) / Electronic Medical Record (EMR): For example, Therapy Notes.
  • Electronic Data Interchanges (EDI): Electronic claim / Electronic version of the Health Insurance Claim Form (HICF) or Centre for Medicare Services 1500 (CMS 1500)
  • Verification of Benefits (Vob): Eligibility of benefits check – verify with the insurance what the patient owes and whether or not the insurance is going to pay and also whether or not the patient is active with the insurance company.
  • Deductible: The set amount that the patient needs to pay before insurance benefits kick in
  • Co-Insurance / Co-Pay: The amount the patient should owe when they’ve met their deductible. The co-pay is a flat rate, while the co-insurance is a set percentage.
  • Stop Loss / Out of Pocket Maximum Amount: The maximum that your patient should pay for healthcare services in the given term of the policy.

Fraud, Audits And Not Screwing Up Your Business

If you’re not breaking the law, audits can be a lot of fun. It’s like arriving at a test, and you’re prepared. You can use the audit as a check and balance for your systems. Don’t be afraid of auditing. A lot of things are fixable, and an audit can be an enjoyable process. 

Be sure to get your systems in order. Know what you need to do from a contractual perspective with the insurance companies that you work with. Know what you need to do to stay compliant in your claims submissions and processing, and track everything.

Fraud: The knowledge of a requirement to collect co-pays and deductibles and billing insurance only. 

False Statements: Billing insurance (a charge) and failing to collect the co-pay / deductible. 

The insurance companies and the government will see discounts around co-pays and deductibles as both fraud and false statements.

In an audit, they look at what services are you billing, and are you collecting from your patients. 

Fines for fraud can be hefty, they typically start at $10,000 per occurrence.

Make sure you’re collecting co-pays and deductibles. Have a regular routine with regard to the flow of payment.

Health insurers don’t aggressively pursue widespread fraud. More often than an audit, premium payments will go up in an area. Insurance companies are looking at the flow of money from a macroeconomic perspective in a certain market from the insurance company for services versus patients. If those numbers don’t match up, they’ll just raise the premiums.

Audits are all about what you can prove and not what you believe. Auditors will sample some of your patients, there’s no way to know which patients are going to look at. If they find issues, they will dig deeper. 

Set up your systems in an airtight way so that you’re collecting everything you should be collecting. 

If you use an Electronic Health Record, all the necessary data is included in the EHR. This makes auditing really easy.

If you think of your business as an eco-system and ask yourself “Do I have every silo of my business documented and optimised so that if I do any kind of quality insurance check, I know what should be there?” If so, you have no need to worry about being audited.


Tech In Billing Insurance To Save Time And Money

Can I save time and money with billing insurance tech? What are some of the platforms available? What terminology do I need to understand?

These are some of the questions we address in this video, talking all things tech in billing insurance, to save you so much time and money.

We discuss what to look for in an EHR such as:

  • Submitting claims electronically
  • Taking care of most of your business like payment posting, denial and rejection follow up, clinical documentation, and more
  • Matching your budget

The best way to start with regards to using tech in billing is by making use of an Electronic Health Record (EHR) system, for example, Therapy Notes. Therapy Notes is the best when it comes to billing for insurance.

What to look for:

  • If you can submit claims electronically
  • An EHR that takes care of most of your business, for example: payment posting, denial and rejection follow up, clinical documentation, etc.
  • An EHR that matches your budget

Find out which insurance companies you work with who use an electronic portal. These companies have agreements with insurance companies where they house eligibility data, claim status enquiry data, etc. Calling an insurance company can be demoralizing and take time. Instead, you can simply search these databases for the information you’re looking for.

If you’re not credentialed yet, there are three portals you’ll need access to:

  1. CAQH: houses provider data so that you can get in-network with insurances faster
  2. NPPES: use to get your NPI
  3. PECOS: medi-care credentialing system

Use LastPass to keep your login information safe.

Use Zoom for any teletherapy.

Make use of a HIPAA compliant credit card processing system.


Your Insurance Billing Plan

Case Scenario: Jeremy is a client of Joe’s.

Jeremy sends Joe all his insurance information. Joe is in-network with Priority Health.

Joe does eligibility of benefits check.

Jeremy receives text reminder / call / email that he has a co-payment of $20.

They set up an appointment, Jeremy receives an appointment reminder, and they do intake. Joe does his notes and billing right away. 

Jeremy pays $20 to Joe.

Joe submits Jeremy’s claim for date-of-service. Claim takes 14-20 days to process. Joe and Jeremy receive EoB that the claim/s has been denied. 

Joe follows up on claim and documents resolution. Perhaps sends in appeal and let’s patient know what’s happening. 

Claim/s get paid.

Joe makes sure that payment and session in electronic health record system match. Once happy, he posts it and claim then ‘falls off’ ageing report (shows how long a claim has been unpaid). The record of this transaction is then saved in your EHR.

Make sure you document your eligibility check. 

Also have a system to follow up on claim denials. 

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