third party insurers

The following tips for filing third party insurance was designed to help practitioners receive maximum reimbursement while avoiding claim denials:

• Get a referral from a physician prior to seeing any HMO patient (PCP); a referral is needed for each “episode of care”; consider creating a faxable referral form to provide to referring physicians as part of their referral package.
• You must have a current copy of the CPT, ICD9, and HCPCS manuals. These may be purchased from:

» American Medical Association
» Medical Arts Press
» Ingenix Online

• Request co-payments or deductible payments at the time of visit, especially in January through March, when annual deductibles may not have been met; it costs money to bill the patient. (AMA statistics show the average cost for in-practice claims filing is $11.50 to $18.00 per claim.)
• Every office must have a comprehensive patient information sheet.
• Patient information sheets should include HIPAA Notice of Privacy Practices Acknowledgement.
• Request private pay billing for the Epley Maneuver, tinnitus retraining and cerumen removal; billing and reimbursement are difficult for these procedures, especially in private practice.
• Make copies of your patient’s insurance cards; you may need the information the card supplies after the patient has left.
• Realize (and help your patients accept) that insurance does not pay for 100% of anything they want.
• Create an insurance verification form and process for your office.
• Every office must have a Fee Bill (Superbill). Claims are most often denied because of a coding error; use of a fee bill minimizes errors.
• Study bundle procedures, coverage amounts and allowable services for each insurance plan you contract with.
• When negotiating insurance contracts, require insurance carriers to contact you in writing whenever there is a significant change in Audiology service payment.
• “Carve out” hearing aid coverage from managed care contracts whenever possible so your practice is not obligated to accept their payment schedule for amplification. Specifically this means that when negotiating an insurance contract including hearing aid coverage, try to exclude the hearing aid coverage within the terms of the entire contract or create a contract portion specific to hearing aids that is more favorable to your practice.

EXAMPLE
You have offered to accept a 30% discount off of regional usual and customary charges for diagnostic services and a patient cannot be balance billed for the difference. The carrier wishes to include hearing aid coverage as well, but you do not want to commit to that same 30% discount and balance-billing restriction for hearing aids. If the carrier insists that a hearing aid benefit remains, it would be better to propose an amendment to the contract setting up a standard dollar amount benefit solely for hearing aids and have the ability to balance bill the patient for the difference between this and your usual hearing aid fees.

• Do not charge different amounts for different patients or insurance companies; create one standard fee for every procedure, service and product and charge that fee to every patient or insurance carrier.
• When scheduling an appointment, ask if a referral or authorization is necessary; you cannot bill if a referral or authorization is required and you did not get it.
• Send a pre-determination letter or complete an extensive insurance verification process prior to rendering hearing aid services, implantable hearing aids, assistive devices, and cochlear implants; request a response in writing, whenever possible.
• Submit insurance claims electronically where possible.

MAJOR INSURANCE CARRIERS

» Aetna
» Anthem
» BlueCross/BlueShield
» Champus/TriCare
» Cigna
» CNA
» Great West
» Humana
» Kaiser
» PacificCare
» Physicians Health Care
» SecureHorizons
» UniCare
» United HealthCare
» WellPoint

If you have any specific questions, visit the reimbursement forum or send an e-mail to the ADA Help Desk.

SAMPLE FORMS AND DOCUMENTS

» ABN
» Fee Bill
» Insurance Verification
» Pre-Determination Letter

 

DISCLAIMER: The foregoing information is provided as a resource for our members. It is not intended and should not be construed as an endorsement of any of the vendors or their products or services; as such, ADA makes no warranty whatsoever, either express or implied, including the warranties of merchantability and fitness for a particular purpose regarding any of the products listed above and makes no recommendation as to the accuracy or suitability of the information for your particular situation. ADA members are encouraged to seek legal counsel to ensure compliance and are responsible for their own knowledge of both federal and state policies as it pertains to HIPAA. Neither ADA, nor any of its officers, directors, agents, employees, committee members or other representatives shall have any liability for any claim, whether founded or unfounded, of any kind whatsoever, including, but not limited to, any claim for costs and legal fees, arising from the use of these opinions.