Insurance reimbursement is in a class of its own when trying to get paid for services rendered. Questions arise, payments get denied, and providers get frustrated. Here is a quick tip guide to streamline your insurance reimbursement process and get paid in a timely, low-stress manner.
#1. Get Connected:
Contact your local insurance company such as Aetna, Blue Cross/Blue Shield, Cigna, HealthNet, etc. Talk to a representative on how to become a provider.
Fill out the necessary paperwork and make sure to have a specific point of contact for future questions, such as billing or eligibility, to simplify your time.
Get an NPI number, a National Provider Identifier, required by HIPAA for all health care providers.
Get an EIN number, Employer Identification Number for tax purposes and claim form submissions.
#2. Policies and Procedures:
Know the ins-and-outs of the system such as getting patients, confirming eligibility, submitting claims, and getting reimbursed.
Get training on these processes. If no training is offered, request for an in-house training session with your representative. Different insurance companies have different procedures.
For example, Aetna PPO on the west coast has the following procedure: a patient will call the dietitian and request services. The dietitian requests that the patient confirm his/her own eligibility. However, it is always best for the dietitian to double check and make sure the patient is eligible by calling Aetna directly and providing the patients name, date of birth, insurance policy number, and diagnosis and service codes. Make sure to note the date and time of the call, the representative you spoke to, the co-pay/deductible of the patient, and the number of eligible visits. After seeing the patient, the dietitian submits the claim form via Office Ally, an online claim form program. The dietitian is reimbursed. If the dietitian is not reimbursed, the dietitian must call Aetna again, talk to a representative, and have the claim re-submitted with the correct information.
#3. Dot Your I’s and Cross Your T’s:
Know your service codes, diagnosis codes, and claim forms. Get a list of acceptable codes by the insurance provider, for different insurance companies accept different diagnosis and service codes.
Know how to fill out the claim form correctly so that the claim does not get denied and you don’t need to re-submit the claim form. Request a completed sample claim form to have a guideline on how to accurately fill it out.
Know your billing rate for every unit charged (how much you are paid for your time). This will be an agreement established during your initial contract with the insurance company.
ICD-9 code: a code of reference for the patient’s medical condition or diagnosis such as 278.00 which stands for Morbid Obesity, Unspecified. The insurance company will have a list of acceptable ICD-9 codes.
HMO plans require a referral from the doctor and the doctor will provide the ICD-9 code.
PPO plans do not need a referral and the dietitian will need to provide the ICD-9 code based on the patient’s medical necessity.
Procedure/Service Code: CPT code: a code describing the type and location of therapy received such as Medical Nutrition Therapy.
97802 (initial office visit), 97803 (follow-up office visits), 97804 (group office visits), S9470 (Nutrition Counseling).
CMS 1500 Form: Health Insurance Claim form to bill for services. Some insurance companies have these forms electronically.
The American Dietetic Association also has a great resource on reimbursement for members only.