Maximizing Insurance Reimbursement

The world of insurance reimbursement for CAM providers has become increasingly difficult over the past two years.  In particular the new CareCore authorization required for Regence BCBS OR, WA, ID, UT plans to access care is extremely limiting.  For Physical Therapists in particular they have to complete so much paperwork (sometimes 45 minutes between charting, completing the forms and submission) in combination with the restricted number of visits per illness, that patients truly cannot get better.  The Oregon Physical Therapy Association is currently collecting statewide data about how Oregon PT's are able or unable to adequately provide care now, and we can certainly speculate where that is going...

But I digress - despite all the new challenges being born out of insurance company fear around insuring the previously uninsured, there are still some reasonable interventions we can take to maximize our reimbursements.

Here's a little step by step guide towards auditing your services and reimbursement rates towards making the most of your fee schedule and your billing practices:

1. Collect Reimbursement Data - the first step is to survey your Explanation's of Benefits and make a list of what different insurers reimburse for the codes you use most.  If you haven't done this in the past year, I highly recommend you do so - the results can be rather eye opening.
2. Audit Services, Coding and Fee Schedule - now take a look at how you treat and what you do.  Do you do any cupping, gua sha, tuina or other bodywork? Do you provide regular nutritional counseling? Use a heat lamp?  All of these things have individual codes - are you using them? List all the codes that would accurately reflect what you do in a typical new patient, return patient, or other type of regular treatment and compare how you are actually coding with how you could be coding.
3. Compare Services and Reimbursement Data - now that you have both your reimbursement per code list, and an audit of what you do compared to what you code, it is time to line them up.  Can you spread your fees out over more codes to more accurately reflect what you do, and would this result in increased reimbursement?  If so, you should!
4. Be Consistent and Fair - remember that you should never bill an insurance company more than you would be willing to charge a patient - there is always a chance the claim will be denied and will become patient responsibility.  A time of service discount should also be no more than 30%, better to be 20% or less.  You should bill consistent code sets to ensure that your billing practices are fair.
5. Adjust Fee Schedule - using the information gathered above, you can now do the math, make decisions and adjust your fee schedule accordingly.  Your fee schedule and your code sets or bundles for new patients, return patients etc. should accurately reflect what you do, match your chart notes, and result in you getting paid fairly for service!

If you're new to insurance billing and need a step by step guide from the ground up, you should consider purchasing my book Insurance Billing Made Easy - it is designed to help you plan a fee schedule and bill consistently and easily to maximize your profits.

Until next time, happy billing!!

~Rebecca