Understanding Private Insurance Qualifiers And Their Billing Impact

Billing insurance can be a complex process, especially when it comes to understanding the different components of a claim form. One such component is the qualifier, which is used in conjunction with provider numbers to indicate the type of provider. For example, when entering a provider's Medicaid Number, one would select the 1D qualifier for both the Individual Qualifier and Group Qualifier fields. Qualifiers are only displayed on paper claims, with the exception of Medicare, where PTANS and 1C Qualifiers are not transmitted electronically.

Understanding the basics of insurance billing for therapists

Insurance billing is a complex and often frustrating task for therapists and clinicians. It involves navigating a web of insurance companies, plans, and requirements, as well as understanding the billing process and necessary codes. Here's a guide to help you get started:

Credentialing and Contracting

The first step is to become credentialed with insurance companies. Credentialing is the process by which insurance companies verify your qualifications, practice, skills, and licensure. It is necessary to become a recognised provider and submit claims for reimbursement. Each insurance company may have its own requirements, but common documents needed include a valid license to practice, a tax ID or SSN, a CAQH provider ID, and a National Provider Identifier (NPI). You can create a CAQH Pro View account and upload your credentials and information, which many insurance companies use for credentialing.

Once credentialed, you will need to contract with the insurance company. Review the contract carefully, paying attention to your approval date, contracted rate, and requirements for billing and claims submission.

Understanding Insurance Terminology

There are several key terms to understand when dealing with insurance billing:

• In-network provider: A therapist who is fully credentialed and contracted with a specific insurance company, allowing them to accept referrals from clients with that insurance.
• Out-of-network provider: A therapist who is not fully credentialed or contracted with an insurance company. Claims submitted by out-of-network providers are usually denied unless the client has out-of-network benefits.
• Copay/Coinsurance: A predetermined, fixed fee that the client pays at the time of service, which varies depending on the provider and type of service.
• Deductible: The amount a client pays before the insurance plan starts contributing.
• Prior Authorisation: Approval from the insurance company for a specific treatment, sometimes required before providing the service.
• Claim: A request for payment that you submit to the insurance company after providing a service.

Billing Process and Technology

Developing efficient billing processes and utilising technology can streamline insurance billing. You can outsource billing, use practice management software, or do it manually through the insurance portal. When submitting a claim, you will need to include client information, practice information, diagnostic codes, service information (CPT codes), and sometimes taxonomy codes and modifiers.

Understanding Client Insurance Plans

Before billing, it is crucial to understand your client's insurance plan and eligibility. Verify that their plan is active, and check if the services you provide are covered. Determine if there are any copays, deductibles, or prior authorisations required.

Submitting and Tracking Claims

Submit claims in a timely manner, either electronically or via paper forms. Keep track of your submitted claims and their status to ensure they are processed and paid. If a claim is denied, stay calm and review the information provided. Contact the insurance company if there are discrepancies or errors.

Clean Claims

A "clean claim" is industry jargon for a claim that is complete, factually correct, and correctly formatted. Using the correct format, usually the CMS-1500 form, and providing all the necessary information reduces the likelihood of your claim being denied due to administrative errors.

Unlisted CPT Codes

In some cases, you may perform a treatment that does not have a specific CPT (Current Procedural Terminology) code. In such instances, you can use an "Unlisted CPT code" as a placeholder and provide a detailed description of the service.

Insurance billing for therapists can be a challenging process, but understanding the basics and staying organised will help you navigate it effectively. Remember to familiarise yourself with insurance requirements, stay up to date with coding changes, and always double-check your claims for accuracy.

Knowing what to do before billing insurance

Billing insurance can be a complicated process, and there are several things to keep in mind to ensure a smooth and efficient billing procedure. Here are some key steps to follow when preparing to bill insurance:

Understand the Credentialing Process

Credentialing is the process used by insurance companies to verify that a healthcare provider is qualified to serve on their panel. It is important to note that insurance companies may not be accepting new providers onto their panels, and the credentialing process can take months. As such, it is advisable to contact the insurance company directly to inquire about their specific requirements and timelines.

Obtain Necessary Credentials and Licenses

To bill insurance, healthcare providers must have the necessary credentials and licenses. This includes obtaining malpractice insurance, being licensed in the state where services are provided, and knowing the relevant taxonomy code for Medicaid and Medicare providers.

Know Your Client's Insurance Plan

It is crucial to understand your client's insurance plan to ensure accurate billing. Ask the client for their insurance company name, ID number, and group number to verify their insurance coverage. Additionally, review the copays and coinsurance that the client is responsible for paying at each session.

Verify Coverage for the Treatment

Not all insurance plans cover the same treatments. Therefore, it is important to verify with the insurance company that the specific treatment being provided is covered by the client's plan. This includes obtaining pre-authorization or pre-certification for procedures that require prior approval.

Understand the Billing Process

Familiarize yourself with the insurance company's billing requirements and guidelines. This includes understanding the claims submission process, whether electronic or paper claims are accepted, and the required documentation and coding for the services provided.

Keep Detailed Records

Maintain detailed records of each client's insurance information, including copies of their insurance cards and driver's licenses. Additionally, keep a record of the dates of service, descriptions of services provided, and any amounts billed or paid. This information will be crucial for accurate billing and addressing any disputes or discrepancies that may arise.

The importance of credentialing

Credentialing is a critical process in the healthcare industry, serving as a verification step to ensure that healthcare providers are qualified to serve on insurance company panels. This process is particularly important when billing private insurance, as it establishes that the provider is legitimate and qualified to receive reimbursement for services rendered. While credentialing can be a complex and time-consuming process, it is essential for maintaining trust and confidence between patients and healthcare providers.

The credentialing process typically involves verifying a physician's education, license, experience, certifications, affiliations, and more. It ensures that providers have the necessary qualifications, skills, and eligibility to practice and offer quality care to patients. This process is crucial for healthcare providers to be in-network with insurance companies, allowing them to receive payment for their services through their patients' insurance plans.

One of the key benefits of proper credentialing is the ability to expand the patient base by accepting various insurance plans, thereby increasing practice revenue. Being listed as an in-network provider on insurance websites improves visibility and credibility, attracting more patients. Additionally, credentialing helps streamline administrative tasks, reducing overhead costs associated with billing and claim processing.

It is important to note that credentialing is not the same as licensing. While a medical license indicates that a physician has passed the state's medical boards and has the appropriate knowledge and education to practice medicine, credentialing provides additional verification of qualifications and skills.

The credentialing process can be lengthy, and it is recommended to start by researching which insurance companies and plans are commonly used in the provider's area. Once relevant insurance carriers have been identified, the provider must submit a pre-application or participation request, allowing the insurance carrier to conduct an initial background check. This is followed by gathering and submitting relevant information, including personal, professional, and practice details. The insurance company then performs a thorough credentials verification, and upon approval, the provider enters the contracting phase, where reimbursement rates and other details are negotiated and finalized.

To manage the demanding credentialing process, many medical practices assign a dedicated person or use credentialing software. Credentialing software solutions can automate various tasks, track provider credentials, manage documentation, and send out applications.

In summary, credentialing is of utmost importance when billing private insurance as it ensures that healthcare providers are qualified, legitimate, and eligible to receive reimbursement for their services. By undergoing the credentialing process, providers can establish trust with insurance companies and patients, expand their patient base, and streamline administrative tasks, ultimately enhancing the overall efficiency and quality of patient care.

How to apply for credentialing

The process of credentialing is a critical step for healthcare providers venturing into private practice. Credentialing is the process by which insurance companies verify your education, training, and professional experience to ensure you meet their requirements for serving as an in-network provider. Here are the steps to apply for credentialing:

• Prepare for Credentialing: Obtain your professional liability insurance policy and ensure you are fully licensed in the state where you will provide services. This includes obtaining your National Provider Identifier (NPI) number, which is required for billing and reimbursement.
• Complete the CAQH Application: The Council for Affordable Quality Healthcare (CAQH) application is often used by insurance companies as part of their credentialing process. You will need to be invited by an insurance company to complete the CAQH application. It is recommended to complete the application online, as the paper application is lengthy and may not be processed efficiently.
• Contact Insurance Companies: Decide which insurance companies you want to be in-network with and contact them to obtain a credentialing application. Major national plans to consider include Aetna, Blue Cross Blue Shield, Cigna, United Healthcare, Humana, Medicare, and Medicaid.
• Complete and Submit Applications: Carefully fill out the credentialing applications, providing all required information and documentation. This may include practice locations, licenses, insurance, and board certifications.
• Follow Up: Credentialing can be a lengthy and challenging process, with applications often getting lost or delayed. Stay in regular contact with the insurance companies to ensure your application is received and being processed. Be responsive to any requests for additional information.
• Review and Sign Contracts: Once your credentialing application is approved, review the provider contract carefully. Understand the terms of participation, reimbursement procedures, claims submission requirements, fee schedules, and any other important contract terms.
• Maintain Credentials: After becoming credentialed, regularly access the insurance company's website to confirm your listing in their provider directory. Record all important contact information, provider IDs, and effective dates. Keep your credentials up to date, including your CAQH profile and NPPES records.

The credentialing process can be time-consuming and complex, often taking several months. It is essential to plan and be prepared for the various steps involved. By following these steps, healthcare providers can successfully navigate the credentialing process and establish billing procedures with insurance companies.

What to do after getting credentialed

Once you have been credentialed, you will be able to access the provider portion of the insurance website. You should create a username and log in to the insurance company's website, where you can view client policy information, claims already paid, and claims in the queue. It is also important to record the insurance company's phone numbers for provider relations, claims department, and service pre-authorisations.

After credentialing, you will be ready to begin billing the health plan for your services. It is recommended that you verify patient benefits before treatment, collect co-payment and/or co-insurance at the time of treatment, and submit your claim within 24 hours of treatment. You should also know the time in which the plan is required to pay your claim according to your contract and follow up on any claims that have not been paid within that timeframe. It is also important to promptly post insurance payments and bill the secondary payer (insurance company or patient) for any balance.

Being credentialed allows you to expand your patient base by accepting a variety of insurance plans, thus increasing practice revenue. Being listed on insurance websites as an in-network provider improves visibility and credibility, attracting more patients. Insurance credentialing also helps providers access a broader number of insurance benefits for their patients, enhancing the affordability and accessibility of healthcare services. Credentialing helps streamline administrative tasks, reducing overhead costs associated with billing and claim processing. Being credentialed with insurance plans can also indirectly affect patients' insurance deductible costs by giving them access to lower-cost healthcare services within their insurance network. Ultimately, it facilitates better patient care by ensuring seamless coordination with insurance carriers.

Frequently asked questions