Here is what you need to know:
The Patient Summary Form was created for certain UHC plans to provide the insurance company with an explanation for the patient’s visit and confirm the need for treatment. The Patient Summary Form must be submitted via fax or on-line and the timely filing deadline for providing this documentation is 10 days from the date of service.
Failure to timely submit the Patient Summary Form will result in loss of payment. If the claim is denied, an appeal may be filed but payment will only be received from UHC if you provide an “acceptable” explanation; leaving the chances of payment solely up to UHC’s discretion.
There are two options you can use to determine if the patient has a plan with benefits that require a Patient Summary Form. You can either call Optum Health Care Solutions at 1-888-329-5182 or log onto www.myoptumhealthphysicalhealth.com and use the “quick group check” utility located in the "Tools and Resources" section.
It doesn’t take long to check and submitting the form in a timely manner will ensure payment and eliminate the hassle of having to file an appeal. We hope this helps you “ Get Paid Right the First Time ”.
If you have a billing problem you need solved, let us know at 508-422-0233. We can help!
The front desk is a biller’s biggest asset when it comes to getting paid for all the hard work you put in with your patients. Understanding this relationship and how these two roles work with one another is crucial for a successful practice.
There are many things a front desk must do before the patient’s information gets to the biller. This includes providing benefit checks, entering patient demographics and managing referrals and authorizations. If any of these essential functions are not done accurately and timely, major problems will arise when it comes time for the biller to submit claims and get paid right the first time.
The front desk must check each patient’s insurance benefits before their first visit. We also HIGHLY recommend that your front desk encourage the patient to check their benefits as well. This helps to avoid getting conflicting information. If there is an issue, it can be addressed immediately.
There are many easy ways to get this job done fast and correctly. In most cases you can go through the insurance portal or clearing house but there will be times when you just have to pick up the phone and call.
We have seen many denials that could have been avoided if a benefit check had been done. For example, some of these denials might include patient’s insurance was terminated, the therapist is not in network with patients carrier and the patient has no out of network benefits. If treatment begins before these issues are addressed, there is a good chance that the biller will not be able to send a successful claim and get payment for that visit.
Over the years, many of my clients have been practically shut down all because they did not change the business address when they moved or added a location. There is a lot of stress when moving but not changing the business address can directly affect your revenue stream.
As a consultant I am called in to practices to evaluate the billing function and to answer questions like why are we getting so many denials, why aren’t our payments consistent, how do we know we are charging correctly, are we in compliance and most of all where is my money? And this is on the heels of investing in and implementing a new billing system.
We have all read articles on choosing the right system and they all promise that you will get better payments, stay in compliance, and your ability to charge and document will be enhanced, but the truth is, in order to get paid and get paid right the first time you need a competent, well trained staff and processes in place to support your goal – payment for services rendered.
There are great benefits to buying a new billing system, especially if it is an “all in one”, billing, scheduling and documentation system. Those that are not can be more difficult to guarantee an accurate flow of information back and forth. Investing in a new system for your practice can make a huge difference in staff productivity, improved documentation and charging for services.
Beware not all systems will work in your favor. Sales people will tell you things like: your profits will soar, you will always be in compliance and the system will do everything for you and the demo will be equally enticing – “it’s like magic”.
And there’s more - if you purchase this system you will begin to make more money almost immediately and the system is so easy to use. It’s great for a start-up, a small or large company, good for 1 or 100 sites and the list goes on. But before you choose, answer some questions.Why are you getting a new system? Who will help you choose a new system? Did you really drill down on the problems with the old system so you would not face the same issues again?
The truth is, there is not one system out there that will do “everything” the way you want but there are some that are much better than others. The best systems will hold their promises if there are skilled people maximizing all functions. Everyone will need extensive training. You have to put great info in, to get great info out.
Beware of the older or free systems out there that cannot bring your business to a new level. Those systems tend to keep you down and buried in the manual systems of entering charges, payments and have reports that are difficult to read and useless as a tool for managing the practice. Usually, you pay nothing and get as much to show for it.
Many sales people know how to use the system they are selling but they have little experience with using it in a real life situation such as your practice or in various states that have some specific requirements.
Here are some specific things to consider when investing in a new billing system.
After years of consulting and billing, one of the hottest issues is how to improve patient collections. The responsibility of collecting patient payments is a front desk requirement. While some are great at collecting at time of service, too many find it difficult to ask for money and many do not try, even though they know the payment is the patient’s obligation.
Getting your providers or group credentialed and contracted may sound straight-forward but often times it can be anything but. Problems can arise at any point during the credentialing process and if you aren't quick to find the solution, you could find yourself starting from square one.
Let's take a look at some examples of credentialing issues from the beginning to the end of the process so you can learn from other's mistakes.
Jack has experienced a lot of success as a sole proprietor of his business. Jack has had so much success that he is thinking of opening a new location and hiring new therapists. He stops by Diane’s office to discuss the credentialing for his new practice. Jack sits down across from Diane and says, “So I am really excited about this new location, we are signing the lease this week. Hoping to start in about a month.”
Right out of the gate, Diane has some questions for Jack to make sure he is prepared for all the credentialing speed bumps that could come up. “That’s great Jack. Have you gotten your type 2 NPI yet?” Diane asks, the second the question is asked Diane can tell that Jack has become unsure of himself. “A type 2 NPI? No, I don’t think I have one of those” Jack said.
“No problem, you can apply for one online, and they’ll email you one within ten days. But you will need a type 2 NPI in order to credentialing your business as a group provider,” Diane explains to Jack. They then visit the NPPES website and apply for Jack’s type 2 NPI.
Later that week, Diane receives a call from Jack, “I received my type 2 NPI for the business, thanks for letting me know I needed that. Anything else I’ll need before I can begin the credentialing process?” She then goes on to inform him of all of the different things that will need to be in place so his credentialing can go smoothly. Jack couldn’t believe that so many other things had to be in order before he could enroll with different insurances, but he was glad he had a resource to make the process easier.
Penny is the owner of her own physical therapy private practice, and has worked there for over 10 years. Penny wants to start seeing less patients so she can spend more time managing her staff. Her current administrative employee is on vacation for the week so Penny takes it upon herself to make some follow up calls on the credentialing for her newest therapist.
Penny starts by calling Blue Cross Blue Shield, “Good morning, I am looking to get the status of an application that was submitted for a new provider.” She then goes on to give them all of her identifying information, but is surprised when the representative says, “I’m sorry ma’am, that application has been rejected because we requested a copy of the provider’s liability insurance and it was not sent within 30 days.” Penny hangs up and becomes frustrated, now her new employee must wait even longer to start treating Blue Cross Blue Shield patients. When Penny checks the admin email account, she sees there are multiple unread emails from insurance agencies requesting provider information.
When Penny’s admin employee returns from her vacation Penny asks her why these emails were not addressed. The admin employee explains, “With the scheduling of patients, calling on authorization/referrals, and all of the other daily tasks I have, it’s difficult to make time to follow up with the credentialing.” Penny then explains to the employee how important provider credentialing is to getting paid for services provided. While the employee promises to make credentialing more of a priority in her day, Penny’s new therapist still has to wait an extra 60-90 days for the new application to get submitted and approved.
Brittany was extremely prepared when she opened her business, she was organized and thorough. She did all her credentialing herself which was a point of pride for her. Brittany began seeing patients and her billing company began submitting claims. Her billing company explains that the claims are getting rejected at the clearinghouse because she isn’t a provider. “That’s impossible, I have the approval letter right here in front of me,” Brittany explains to the billing rep over the phone. The rep then asks, “Did you put that provider number in the clearinghouse, and get approved to submit electronic claims?” Brittany then pauses for a minute and thinks about the question. “Well no, I didn’t know that was something I had to do. I thought I just got credentialed and I could start submitting claims.”
The rep then goes on to explain that getting set up through the clearinghouse is an important step to the credentialing process, while it doesn’t involve the insurance company directly, it is necessary to send claims and receive payments. Brittany makes a note of this information, so when she hires a new therapist and does their credentialing, she’ll be sure to remember this step.*
The credentialing process is a complex one, that requires accurate applications and rigorous follow up. Outsourcing your practice's credentialing to experts will ensure that your applications are submitted correctly the first time, and follow up is made routinely so you know your application is going to the appropriate channels. To learn more about Account Matters credentialing services, give us a call at 508-422-0231.
Once you begin the credentialing process for your new business, you’ll discover that the insurance companies have a long list of required documents that you will need to submit in order to verify the legitimacy of your business. One of the biggest issues that we run into when credentialing a client is that the information on these documents do not match. That’s where the trouble begins…
Physical therapy is one of the fastest growing healthcare industries in the country, with new private practices opening daily. This is great for patients because the number of clinics they have to choose from is larger, but not great for new owners, because many insurance panels are being closed to new groups.What is a closed panel?
To see a patient who wants to use their "in-network" benefits, you will need to be an “in-network provider”. This means that you have been credentialed and contracted with the patient's insurance company. When an insurance company feels that they have reached the adequate number of providers for a specialty, they will close that panel and no longer issue contracts for new providers/groups. This can be extremely frustrating for a new business owner.