The Imperfect Nature of Billing


Imperfect Bowl

Insurance billing is a complex process. There are several different entities involved in the entire process, multiple submission methods, and constantly evolving regulations and processes for submitting claims. Due to the high level of complexity, there is a lot of room for error. There are many measures that you can take to increase your chances of clean claim processing, yet there is no way to guarantee a 100% success rate. There are however productive ways to deal with the imperfections of the billing process. In this post, we will talk about some of the ways that the insurance system yields imperfection, and how best to navigate the complex world of insurance billing.


The Players in the Game

A claim passes through the hands of many different people, and each of them has a different role in the process with different stakes in the insurance game. Below is an overview of each of the different parties involved and how they affect and are affected in this process.


The Insurance Companies

The insurance companies offer a level of shared risk in our society. For all intents and purposes, the insurance company can be thought of as your employer. They cut the checks after all! In order for them to be successful, they need several things to be true: they need to have quality providers in their network, they need to have balanced and proportionate numbers of providers within their network based on their number of customers, and they need to have strict verification policies in place to ensure that payments for claims are going to the correct (and legitimate) people. The process of credentialing is like applying for the job. The insurance company makes decisions on allowing providers in their network by reviewing candidates, and evaluating whether they have a need for that type of candidate, just like a hiring manager would. The process of billing can be likened to submitting a timesheet to your employer, with all activities coded to specific types of “jobs.” As a frequent victim of fraud, the insurance industry has adapted to operate cautiously and frugally. The hoops that have been put in place for claim payouts are meant to protect both the insurance company and you as a provider. This is why the insurance companies are such sticklers about data matching, and why you can’t expect a perfect track record of no claims denied or rejected.


The Insured: Your Patients

Your patients pay the insurance company monthly in exchange for coverage of medical services. Your patients are responsible for sharing any pertinent health insurance information with their healthcare provider (you) to make sure that they are getting the assistance that the insurance company promised. Often, patients may not fully understand their insurance coverage, or the process by which the insurance company will cover or partially cover a medical expense. A patient can neglect to provide you with an updated insurance card, or forget to inform you of a new address.


You: The Provider

You provide a valuable service to your community by advocating for and treating your patients. You likely got into the mental health field because you were passionate about helping others, not because you were passionate about submitting health insurance claims. In spite of that, submitting claims is part of that valuable service you provide if you decide to take insurance patients. Both your patients and the insurance company are relying on you to submit those claims with accuracy, and timeliness. It is your responsibility to credential with insurance companies and inform your patients which insurances you do or do not take, keep that credentialing information up to date with the insurance company, and submit claims with the proper information according to how you credentialed and the patient’s insurance information.


EHR Providers

An EHR is less of a player in the game, and more of a supportive coach. EHR companies were established to help providers move into the digital age, developing software that allowed for storing patient information in accordance with HIPAA guidelines, submitting claims through electronic channels and using stored information to save time in the claim creation process, and scheduling patients using a digital calendar. The EHR companies also do their best to help you stay up to date with ever-changing processes of the insurance companies so that your claims make it to where they need to go. An EHR is a tool to help you!


The Clearinghouse

The rise of the electronic claim brought on an entirely new challenge- so much data from all over the country being transferred! Clearinghouses were established to function as a sort of gatekeeper for all of these claims, ensuring that they are routed to the correct insurance company, using secure protocols, and that the information on the claim is correct before it gets to the insurance company.


Things Can (and will) Go Wrong

With that many people involved in the chain of claim submission, it increases the chances that somewhere along the line some information is incorrect. At the end of the day, each entity is operated by people, and people can make mistakes! But people can also rectify mistakes, and it’s important to be patient and understanding to get to the bottom of any issues.

Not only is there room for human error, but things are frequently changing! Technology grows and adapts quickly, and we will continue to see insurance companies adopting new uses of technology as time goes on. Whenever things change, there can be growing pains, and insurance is no exception.


So What Can I Do?

If you’re feeling helpless, overwhelmed, or confused, the first step is to take a breath. Then continue reading to find out some of the things that you can do to make sure you have the best chance of charting your course through this imperfect maze!


Read Your Contract

When you get credentialed, the Insurance Company will provide you with a contract that outlines your relationship with them. Read that carefully! If there is something that you don’t understand, reach out to your Provider Representative, or consult with an attorney. Having a complete understanding of your contract will take a lot of time (and will power) but will leave you with a much better chance of feeling in control!


Get to Know Your Provider Representative

Provider Representatives are meant to be an advocate for providers within the insurance company. Finding out who your provider representative is and getting to know them can be a very valuable relationship! They can answer any questions, or provide you with guidance on where to find answers.


Collect and Update Patient Insurance Information Regularly

Always ask for a patient’s insurance card, and get an image of the front and back of that card. When possible, run an eligibility and benefits check ahead of time so that you can understand what a patient will owe for any session. Check with patients at each visit to see if there have been any updates to their insurance information.

Read All Emails and Mail From the Insurance Company

We all have crowded inboxes, and it can be easy to get overwhelmed. But remember, the insurance company is your employer- would you ignore an email directly from your boss? If the insurance company is emailing you something, it is likely important information pertinent to you, or a great opportunity to learn something new. When the insurance company sends you something in the mail, it is definitely important. Read through things carefully and if anything is unclear, ask a colleague, your billing company, or your provider rep!


Hire A Professional

Billing is complex! Even the professionals are bound to run into a denial or rejection every now and then. The important thing is that they are experienced in identifying, researching, correcting, and resolving issues. Hiring an experienced biller does not mean that nothing will ever go wrong- it just means that when things do go wrong, you’ve got experts on your side who will do the heavy lifting for you. If you are ready to pass off the stress of billing to someone else, Practice Solutions has you covered! We offer full service billing solutions, specializing in mental and behavioral health. Reach out to our sales department either online at www.practicesol.com, call us at 734-437-9432, or email us at info@practicesol.com!


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