T
he private insurance market is
still going strong, and is another
avenue that the pedorthist has
available to increase revenue and
improve service to their patients.
Just as in the world of government sponsored
insurance, there are many winding roads that
you need to be navigated when accepting this
type of insurance.
When it comes to commercial insurance, the types vary with
the company. Some are traditional fee for service plans (FFS),
where the insured's plan covers any provider's claim. These are
generally the most expensive plans in terms of premiums. In
return, there are more providers who can be paid through this
plan.
The other type of commercial plan is the managed care
model. This is increasingly becoming the standard for many
insurance care plans. The most common forms of this plan
are the Preferred Provider Organization (PPO) and the Health
Maintenance Organization (HMO).
The key to working with all these types of plans is getting
a contract from the carriers; and this is not an easy task. A
contracted provider generally gets a higher reimbursement rate
than a non-contracted entity. The pedorthist has to contact the
individual company's contracting agent to see if there are any
contracts available in their area. New contracts in urban areas
are very hard to come by, especially with the largest companies.
Practices in more rural or "underserved" areas have a better
chance of receiving the coveted contract. Keep trying if you are
not successful the first time. Persistence pays off in the long run.
When you have a contract, you agree to their posted fee schedule
for each plan. In some cases, there is a co-payment required by
the patient, though in many cases, there is not. Reimbursements
from managed care plans are lower than a FFS plan. A
contracted provider will get reimbursements sent to them, while a
non-contracted provider’s reimbursements are sent to the patient.
An example of this non-contracted provider’s reimbursement
being sent to a patient can be seen in the following case where a
person had significant abdominal surgery and the reimbursement
check for the surgery was sent directly to the patient. It just so
happened that the patient thought they had come into a windfall
of funds, and proceeded to promptly remodeled their kitchen.
Apparently the patient did not care that the check was intended
for the doctor.
The insurance company in that case is under no obligation to
force the patient to turn the check over to the doctor. This is
something you need to make sure you are aware of when dealing
with this type of reimbursement. The patient has a contractual
obligation to the doctor to pay for medical services. However
in this example, this patient thought a new kitchen was what he
should be spending the money on. The next stop for them was a
court room.
Even in managed care models, PPO's operate a bit differently
from an HMO plan. The PPO allows the subscriber to choose
from a list of providers who are contracted by the insurance
carrier. Certain services require prior authorizations, so it is
always safe to call and see if a prior authorization is needed.
With an HMO plan, a majority of the services require prior
authorization. HMO enrollees normally have a case manager
assigned to coordinate care. Many of these plans have
extra “goodies” such as prescription coverage or health club
memberships that are used to attract customers.
There are plenty of plans out there that do not allow any "out of
network" providers to bill for their services. It is very important
that you know this before you take on a new patient. "Out of
network" means non-contracted providers. This is especially true
of the Medicare Advantage and some state Medicaid programs.
A patient may say that they have Medicare, which is true, but
it is through the advantage plans, and the rules of these plans
take precedence. To make matters even more confusing, even if
the patient is in an advantage plan, they still get the traditional
Medicare card along with their plan card. For Medicare patients,
check their eligibility with your region's IVR to make certain,
otherwise you are out of luck.
It pays off in certain circumstances to send a claim to an insuror
without being contracted. It is a roll of the dice or you, but you
may get paid. Always inform your patient in writing that even
should the claim be sent, it is not a guarantee of payment, and
that they are liable for the bill. Claims are sent as a courtesy to
the patient, but the responsibility to pay is ultimately theirs. Some
pedorthists have sent in many claims and eventually are offered a
contract in some cases. All it costs you is a stamp or some internet
time.
As technology continues to grow, many carriers are using internet
based submissions for their claims. There are private services
that these insurance carriers contract to forward their claims to
patients. For instance, Aetna and the Blues use Availity (www.
availity.com). Also, all insurance companies have their own
website that will tell you which outfit does their claims. In
addition, these services also provide eligibility information and
a lot of other pertinent information that can help you with your
claims. One big advantage is that the claim goes directly into
their processing system, and that shaves a week or two off the wait
time for your reimbursement.
It is to the pedorthist's advantage to seek out contracts with private
insurance companies. Despite the great amount of trial and error
that you need to do, you will find out who covers what and for
how much. Remember, the key is the contract – get one, and a
bigger piece of the insurance reimbursement pie is available to
you. Good luck.
Current Pedorthics
March/April 2013
43