The Ultimate Guide to Billing Insurance in 2024
January 14, 2024
January 14, 2024
The decision around whether you should be billing insurance for your wellness services is deeply personal. It can encompass factors like quality of care and your personal philosophy around care accessibility. However, choosing to accept insurance can also impact how you run your practice, the selection of services you provide, and even your relationship with your clients.
From a pure business perspective, billing insurance for your wellness services is a valid way to expand your client base and diversify your income streams. It’s definitely worth a deeper look, and we’ve done the digging for you.
Keep reading to understand why billing insurance can be great for business, the nuances between different plans, and how to bill insurance as a provider – including staying compliant, navigating denials, and coding like a pro.
When you think about how to bill insurance as a provider of wellness services, it might evoke images of increased paperwork and jumping through hoops. In reality, insurance billing solutions can offer a sustainable revenue stream for your business.
You need a National Provider Identity number (NPI) to bill any insurance provider. This unique 10-digit identifier is a permanent number assigned to individual healthcare providers or organizations by the Centers for Medicare & Medicaid Services (CMS).
An NPI helps to accurately identify you and smooths out the billing processes with insurance companies. HIPAA (the Health Insurance Portability and Accountability Act) also requires that all covered entities have an NPI. The application is free and the turnaround time to receive your NPI usually takes between 1 and 20 days.
Although your NPI remains the same no matter which insurance company you’re dealing with, there are subtleties you should understand about the different insurance plan types.
Your NPI number can then go into your Practice Better account to automatically add to Superbills and CMS 1500 forms.
Just as the name suggests, private insurance is run by private companies, like Blue Cross Blue Shield and Aetna.
Medicare and Medicaid are both administered by a federal agency called the Centers for Medicare & Medicaid Services – or CMS. There are some key differences between the two programs. It’s also possible for some individuals to qualify for both Medicare and Medicaid, which provides them with superior coverage.
|Federal health insurance for people 65 or older, certain younger individuals with disabilities, and people with end-stage disease.
A person’s Medicare coverage is the same no matter what state they live in.
People with Medicare pay some of the costs. This can take the form of monthly premiums, deductibles, and coinsurance.
|A jointly funded federal-state program providing health coverage for eligible low-income individuals/families.
All Medicaid programs have to follow general rules, but eligibility and coverage vary since it’s administered by individual states.
Medicaid also offers benefits that Medicare doesn’t cover, like nursing home care and personal care services.
People with Medicaid don’t pay anything for covered expenses, but they are sometimes required to make co-payments for particular items or services.
HMOs and PPOs are two popular types of managed healthcare plans offered by insurance providers in the United States. These plans involve networks of healthcare providers and offer different levels of coverage, costs, and flexibility. Here are some key differences between the two:
When you’re working through how to bill insurance as a provider, knowing the common terms used helps to navigate the landscape more easily. Here are five key terms every wellness professional should know. For a more complete listing, you can check out the CMS glossary.
Usually, deductibles outline how much a person is expected to pay per calendar year. Some plans will waive deductibles for certain activities, like office visits. Others have them applied to all services.
So, for example, imagine a dietitian is providing a first-time nutritional counseling session at a rate of $200 for an hour. The client’s insurer might require the client to pay $20 directly to the practitioner. The insurer would then reimburse the remainder directly to the practitioner.
For example, a client might have a $40 co-pay for a $300 therapy visit. This is a fixed amount they pay at the time of their appointment. Their plan may also include a 20% co-insurance payment. This would make them responsible for paying 20% of the amount after their deductible is met.
$300 visit – $40 co-pay = $260
$260 x 20% co-insurance requirement = $52
Total paid by client = $40 co-pay + $52 co-insurance = $92
Total reimbursed by insurer = $300 – $92 = $208
Accuracy matters when you’re billing insurance for your services. Errors can lead to disputes, delays, and lost revenue for your practice. It can also be stressful for your clients if claims are denied and you need to approach them to pay out of pocket for the cost of your services.
You’ll want to ensure that you have all the client details correct when you’re submitting claims for reimbursement. Name, address, date of birth, insurance member ID number, relationship to the insured person, etc. are all important pieces of information to get right the first time.
Make sure to verify coverage details, including deductibles, co-pays, and more. A client presenting you with an insurance ID card is not proof of eligibility. There are typically a few different options you can use to verify eligibility.
When you’re billing insurance claims to private companies versus government programs there are some similarities and differences to keep in mind.
All providers use a standard insurance claim form, whether submitting to private insurance, Medicare, or Medicaid. It’s called a CMS 1500 and it requires specific information to process the claim. This includes client demographics, provider information (like NPI, location and address), policy information, and diagnosis and treatment information by entering the correct ICD-10 (International Classification of Diseases) codes and CPT (Current Procedural Terminology) codes.
Some clients will be covered by multiple insurance plans, for example, if both they and their spouse have private insurance coverage through their employers. Coordination of benefits involves determining which insurance plan is primary when a client is covered by multiple insurance policies. This helps in determining which plan pays first for healthcare services. It also helps clients receive maximum benefits while minimizing out-of-pocket costs.
Remember: Medicare is a federal program so the rules are more consistent across the board:
Medicaid reimbursements vary by state, but there are some general rules to follow:
Medicare and Medicaid offer different models of managed care, including HMO and PPO options. Care providers who want to become part of the network negotiate contracts which also outline reimbursement rates, terms, and conditions for services provided to plan members.
Here are some tips for avoiding the headache of billing insurance providers denying your claims and what to do if it happens regardless of your vigilance.
Remember when the pandemic forced everyone to figure out telehealth really fast? That extended to the U.S. Department of Health and Human Services (HHS). They made administrative changes to relax the rules around telehealth and make it easier to access, deliver, and get paid for services. Some of these changes are permanent and others are temporary.
As rules and reimbursements for telehealth continue to evolve, you can stay up to date through the telehealth HHS hub. on through the HHS.
The correct use of CPT codes is critical for accurate billing and reimbursement. This standardized set of codes is used to describe medical, surgical, and diagnostic services provided to patients in the U.S. healthcare system.
Here are some common CPT codes that wellness professionals use regularly.
|97110 – Therapeutic exercises
|Therapeutic procedures necessary to improve a person’s strength, endurance, range of movement, and flexibility. It covers one or more parts of the body and requires direct contact with a qualified professional, such as a physical therapist.
|Time-based code, billed in 15-minute increments
|97140 – Manual therapy techniques
|Features hands-on techniques including mobilization/manipulation, manual lymphatic drainage, and manual traction.
|Time-based code, billed in 15-minute increments
|97530 – Therapeutic activities
|Cover therapeutic activities over a wide range of rehabilitation exercises. Therapy focuses on mobility, strength, balance, and coordination.
|Time-based code, billed in 15-minute increments
The three CPT codes dietitians use most are outlined below. Private insurers, Medicare, and Medicaid all accept these codes.
|97802 – Medical nutrition therapy; initial assessment
|This code is for an initial face-to-face assessment and intervention with an individual client. It’s used by providers who treat conditions and symptoms using dietary and nutritional therapy.
|Time-based code, billed in 15-minute increments. Can only be used for the first visit with a client.
|97803 – Medical nutrition therapy; re-assessment and intervention
|This code is for follow-up visits. It covers ongoing assessment/treatment using nutritional therapy.
|Time-based code, billed in 15-minute increments.
|97804 – Group medical nutrition therapy
|This code is for treating a group of clients (2+) using dietary and nutritional therapy.
|Time-based code, billed in 30-minute increments of a session to a group of two or more patients.
|98940 – Chiropractic manipulative treatment (CMT), one to two regions
|The provider applies manipulation to influence joint and neurophysiological function by a variety of techniques and modalities in one to two spinal regions – spinal, thoracic, lumbar, sacral, or pelvic.
|Manipulation limited to 1 – 2 regions.
|98941 – CMT; spinal, three to four regions
|The provider applies manipulation to influence joint and neurophysiological function by a variety of techniques and modalities in three to four spinal regions – spinal, thoracic, lumbar, sacral, or pelvic.
|Manipulation limited to 3-4 regions.
|98943 – CMT; extra-spinal
|The provider applies manipulation to one or more of the extra-spinal regions – head region, lower extremities, upper extremities, rib cage, abdomen.
|Manipulation to 1 or more regions.
|90791 – Under psychiatric diagnostic evaluation
|The provider delivers a psychiatric evaluation of a new behavioral health concern with the intent of making a diagnosis.
|Typically billed for the initial appointment, between 16 and 90 minutes in length.
|90832 – Individual psychotherapy, 30 minutes
|The provider performs psychotherapy, a series of techniques for treating the psychiatric disorders of the patient. The treatment session with the patient typically lasts for anywhere between 16 to 37 minutes.
|90832 should be billed for sessions between 16-37 minutes.
Other codes cover longer sessions:
90834 (between 38 and 52 minutes)
90837 (53 minutes or more)
|96130 – Psychological testing, evaluation, and feedback
|The provider administers standardized psychological tests, including interpreting results, establishing a treatment plan, and preparing a report.
|Code covers the first hour of this service. Each additional hour needed to complete the service is billed with the code 96131.
In 2022, the Office of Inspector General (OIG) reported healthcare fraud judgments and settlements accounted for over $3 billion. Complying with medical billing rules requires charging accurately for your services and following the guidelines and laws set out by federal and state governments, Medicare, Medicaid, and private insurance companies.
You can stay in compliance by ensuring you code accurately, document everything, conduct regular audits, and thoroughly train any staff who are tasked with billing insurance.
The transition from ICD-9 to the current ICD-10 increased the number of codes by 13,000. ICD-11 actually came into effect on January 1, 2022, but it’s up to individual countries to decide when they will transition to the updated codes. For context, the World Health Organization (WHO) endorsed ICD-10 back in 1990, but the HHS transition to the new codes didn’t take place until October 2015.
ICD-10 codes are a standardized system used worldwide to classify and code various diseases and health conditions. They are used to help insurers understand the diagnosis related to any treatment and, as such, are an integral part of healthcare billing in the U.S.
Here are some common ICD-10 codes wellness professionalss use every day.
When it comes to how to bill insurance as a provider, the landscape is constantly changing. But the complexity shouldn’t deter you from giving your business access to a lucrative revenue stream.
The key to staying successful with billing insurance is to stay informed (and the right software has a big role to play too)! We can help. Sign up to our mailing list to get the latest updates on insurance billing solutions delivered to your inbox.
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