Four Initial Encounter Tips for Obtaining Timely Claims Payment
Kevin D. Arnold, PhD, ABPP
Most psychologists know that the first encounter, the intake call/email, creates a lasting impression with patients. The amount of time you take to return that inquiry, and how long before the patient can be seen for the first time, are key elements to patient experience and satisfaction.
Equally important is the information you obtain to verify benefits. Most patients provide information from their insurance cards. However, there are key bits of information that are key to making sure your claims are paid in a timely manner.
- Obtaining claims submission data: While the patient will provide the insurance plan to which they subscribe on the initial call, their behavioral health benefits may be provided by a contracted third-party company or carved out. In our practice, we’ve found that the best way to determine if the claims will be paid by the typical payer (e.g., OPTUM for United Health) is to obtain the physical claims address for hard-copy submissions during the benefits call. Those addresses can be used to categorize each payer in your billing system, and will be valuable should a paper claim ever need to be submitted.
- Referring physician: There are several payers that require the referring physician field to be completed in the claims processing. We’ve learned that the claim can be denied during either a) the clearinghouse edits or b) the payer edits processes. The easiest method for managing the potential denial is to avoid it by obtaining and entering the Primary Care Physician name and NPI number during the intake process.
- Employee Assistance Programs: EAPs are a reality in many markets. Often patients are not well educated on how an EAP works, and how to obtain their benefits. During the intake call, you can ask if the patient intends to use an EAP, and educate them on their obligation to obtain the EAP authorization and bring it to the first session. You can also identify if you participate on that EAP, and if it is billed electronically, on paper claims forms, or requires EAP-specific claims processing. These bits of information will ensure you are paid on EAPs as quickly as possible.
- Special insurance products: Many times you will believe your provider has been paneled on a particular plan (e.g., PPO, HMO), only to find that your patient is participating in a specific plan for which your provider is not credentialed when the claim is denied. To manage that risk, be sure to ask for the specific plan name during the intake call, and ask specific questions during the benefits call about your provider and that plan. Many ACA plans have become tailored to specific employers, and the provider panels are narrowly defined (often leaving your provider off without you knowing it at the time). When a denial occurs under these circumstances, you probably have already indicated that your provider is “in-network,” so when you balance bill the patient, the likelihood of an unhappy patient is very high.
Most psychologists have a basic understanding of submitting claims electronically, or contract out billing. But the intake processes are most often handled internally. Most billing companies cannot resolve errors caused by mistaken, or incomplete, information inputted into the patient demographics during intake. When claims are denied because of errors at intake, the claim (in our experience) likely sits in a denied claims cue never to be paid—and becomes stale and unpayable at some point due to untimely filling deadlines. It is always best to see intake contacts as the first step in obtaining payment for claims.
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