Maximizing Reimbursement: Navigating Insurance Billing As A Psychiatric Nurse Practitioner

Billing insurance as a psychiatric nurse practitioner can be a complex and time-consuming process, but it is a critical skill to succeed in the field. The billing process involves using medical Evaluation and Management codes (E&M) to seek reimbursement from insurance companies for services rendered. Psychiatric nurse practitioners often have limited time to manage billing due to their busy schedules, and errors in billing codes can result in lower reimbursement rates or claim denials. To maximize reimbursement, it is essential to have a dedicated billing and coding specialist or seek assistance from expert services. Understanding billing and reimbursement guidelines, staying current with practice guidelines and changes, and proper documentation are key components to ensure efficient billing practices and compliance with regulations.

Understand the different types of reimbursement that Medicare provides for non-physician providers

There are three basic types of reimbursement that Medicare provides for non-physician providers:

• Direct pay: This is when the non-physician provider (NPP) holds their own Provider Identification Number (PIN). They are reimbursed at 85% of the billable physician rate. It is important that NPPs receive their own National Provider Identifier (NPI) and are credentialed with each payer to bill under their PIN number, based on payer rules and regulations. However, many payers will not credential NPPs. Having the NPP credentialed allows practices to bill insurance companies directly when the "supervising physician" is either not on-site or has not provided any care or input into the patient's plan of care.
• "Incident to" billing: This is a way of billing outpatient services rendered by an NPP in a physician's office located in a separate office or institution, or in a patient's home. With this type of billing, the physician bills and collects 100% of Medicare's allowable reimbursement. "Incident to" billing is used when an NPP sees a patient for follow-up care based on a plan of care initially set up by the physician. The physician must be on-site, in the same suite, and provide direct supervision. By filing a claim "incident to", the physician can collect 100% of the Medicare Physician Fee Schedule (MPFS) instead of 85% of the MPFS for care provided by a qualified NPP.
• Split/shared expenses: This is when a physician and a qualified NPP each personally perform a substantive portion of an evaluation and management (E/M) visit face-to-face with the same patient on the same date of service. Billing for shared/split services allows the practice to bill under the qualified physician versus the NPP at their lower reimbursement rate, allowing for an extra 15% reimbursement. This type of billing is applicable for services rendered in hospital inpatient or outpatient settings, emergency departments, hospital observation, and offices or clinics (when "incident-to" requirements are met). It is not allowed in skilled nursing facilities or nursing facility settings, for consultation services, or critical care services.

Learn how to code claims cleanly to avoid delays or denials

Clean claims are the ticket to getting correct reimbursement the first time. Any errors in a claim will likely raise red flags at the insurance company and may cause them to delay or deny payment. Sometimes, making a mistake on your billing codes will result in a lower rate of reimbursement that may or may not seem worth it to appeal.

Incomplete or wrong information

The root of claim denials can come right from the start, during registration. When intake staff don't verify patient insurance and other vital information, they end up sending incomplete or erroneously filled-up claim forms which, of course, end up denied. Make sure that your staff are well-trained in this area. They need to make sure that all information is filled up completely and correctly. You can provide them with a list of the most commonly missed fields, such as specific dates, patient subscriber number, etc. You could also double-check claims before they are sent out, or have a reliable billing company double-check these for you. This process may be a bit more time-consuming, but it is much better than having to endure another denied claim.

Coding errors

Coding errors, such as mismatched diagnosis and procedure codes or incorrect modifiers, are another common cause of claim denials. Providers should invest in robust coding education and training programs for their staff to ensure accurate code assignments. Regular audits and compliance checks can also help identify and rectify coding errors promptly.

Lack of medical necessity

Claims may be denied if the services rendered are deemed not medically necessary. To prevent this, providers should carefully evaluate and document the medical necessity of each procedure or service. It is crucial to maintain comprehensive patient records, including detailed notes on the rationale behind treatment decisions, to support the medical necessity of billed services.

Timely filing limit exceeded

Insurance companies impose specific time limits within which claims must be submitted. Failure to meet these deadlines can result in claim denials. Providers should establish robust processes to track and submit claims within the specified timeframe. Utilizing electronic billing systems and implementing reminder systems can help ensure timely claim submission.

Insurance coverage issues

Claim denials can also occur due to insurance coverage issues, such as expired policies or services not covered under a patient's plan. To mitigate these challenges, providers should verify insurance coverage and eligibility prior to an appointment. Additionally, back-end insurance discovery solutions can uncover hidden revenue where coverage is overlooked, not updated, or otherwise missed. Clear communication with patients regarding their coverage limitations can help manage expectations and prevent claim denials.

Verify patient insurance before they arrive to prevent lost reimbursement

As a psychiatric nurse practitioner, verifying your patient's insurance coverage before they arrive for their appointment is crucial for several reasons. Firstly, it ensures accurate billing and revenue cycle management. By confirming insurance details upfront, you can correctly estimate the patient's financial responsibilities, including copayments and deductibles. This leads to fewer billing errors and enhances patient satisfaction. It also streamlines the revenue cycle management process, ensuring timely payments for your services.

Another benefit of insurance verification is the prevention of claim denials. Incomplete or inaccurate insurance information often leads to claim denials, resulting in delayed or lost revenue. By verifying coverage in advance, you can identify potential issues and resolve them promptly, maximising reimbursement rates.

Additionally, insurance verification improves operational efficiency. Knowing the patient's insurance coverage and benefits in advance allows for better resource planning and scheduling. It reduces wait times and minimises administrative tasks related to claim resubmissions and follow-ups, giving you more time to focus on patient care.

To effectively verify patient insurance, follow these steps:

• Collect Comprehensive Patient Information: Train your staff to obtain accurate and up-to-date information, including insurance cards, policy details, and identification documents. Encourage patients to provide all necessary information during the initial registration process.
• Utilise Technology: Leverage Electronic Health Record (EHR) systems and practice management software with integrated insurance verification modules. These tools enable real-time eligibility checks and automate data retrieval from insurance databases, reducing manual errors and saving time.
• Verify Insurance Coverage in Advance: Encourage patients to share their insurance coverage details before scheduling appointments or elective procedures. This ensures they are aware of their financial responsibilities, and it allows you to make informed decisions about treatment plans.
• Develop Standardised Workflows: Establish consistent workflows and protocols for insurance verification. Clearly define roles and responsibilities to ensure efficient execution of the verification process.
• Communicate Effectively: Maintain open and transparent communication with patients throughout the insurance verification process. Explain insurance terms, coverage limitations, and financial responsibilities to empower patients to make informed decisions.

By implementing these best practices, you can streamline the insurance verification process, improve financial outcomes, and enhance the overall patient experience.

File claims quickly to increase chances of substantial reimbursement

As a psychiatric nurse practitioner, you will be busy seeing many patients for short periods of time, leaving you with little time to manage your practice and billing. Therefore, it is essential to be well-versed in the billing process to ensure you receive timely and accurate reimbursement for your services.

One crucial aspect of maximising reimbursement is filing your claims promptly. While some insurers, like Medicare, allow up to a year or 18 months for claim submissions, it is generally not advisable to wait that long. The quicker you file a claim, the better your chances of receiving a more substantial reimbursement. Some companies even allow for advance reimbursement claims for certain services. Additionally, timely filing can be essential in ensuring your claim is accepted, as insurers may require you to submit within a specific timeframe, such as within 24 hours of an incident.

To streamline the claims process, it is beneficial to have a dedicated tracking system for the claims you have filed. This enables you to follow up with the insurance company if they take too long to respond. It is also crucial to understand the difference between denied and rejected claims. A denied claim is one that the insurer has processed but found unpayable, often accompanied by an explanation. On the other hand, a rejected claim has not been processed due to clerical errors, such as incorrect patient information. Rejected claims are generally easier to rectify, whereas denied claims may require a more time-intensive appeal process.

To summarise, filing your claims promptly is a critical step in ensuring you receive substantial reimbursement for your services as a psychiatric nurse practitioner. By staying organised, understanding the claims process, and acting swiftly, you can maximise your reimbursement and maintain a healthy cash flow for your practice.

Know the difference between denied and rejected claims to save time when dealing with unpaid claims

As a psychiatric nurse practitioner, understanding the difference between denied and rejected claims is crucial for effective revenue cycle management. Rejected and denied claims are the biggest reasons you may not be getting paid, so it's important to know how to handle them efficiently.

Rejected Claims

A rejected claim is one that contains one or more errors that are identified before the claim is processed by the payer. These errors prevent the insurance company from processing the claim, and the claim is sent back to the medical biller for correction.

Common errors leading to rejected claims include:

• Incorrect patient data or procedure/diagnosis code errors
• Missing/invalid provider and payer information
• Mismatched procedures
• Incorrect insurance numbers
• System coding issues

When a claim is rejected, it is not entered into the insurance company's computer system because the data requirements are not met. Rejected claims are typically the result of clerical errors or mismatched procedure and ICD codes.

To address rejected claims:

• Check all patient demographic and insurance information for accuracy
• Verify patient eligibility and benefits
• Obtain prior authorization when needed
• Ensure correct coding and documentation

Denied Claims

A denied claim is one that has been received and processed by the payer but is deemed unpayable. Denied claims may violate the terms of the payer-patient contract or contain errors that were caught after processing.

Common reasons for denied claims include:

• Absent insurance referral or authorization
• Submitting claims outside the payer's timely-filing limit
• Medical necessity issues
• Provider enrollment/credentialing issues
• Missing information
• Non-covered services per plan
• Services not deemed medically necessary

To address denied claims:

• Determine the reason for the denial
• Correct the claim if there was an error
• Appeal the denial or request reconsideration
• Follow up on denied claims in a timely manner

Key Differences

The main difference between rejected and denied claims is that rejected claims occur before being received and processed by insurance companies, while denied claims have been received and processed. Rejected claims can be corrected and resubmitted, but denied claims require an appeal or reconsideration request before resubmission.

Understanding the distinction between rejected and denied claims will help you streamline your billing process, reduce delays, and improve your practice's financial health.

Frequently asked questions