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10 Things You Must Pay Attention to in Your Insurance Contracts (Other Than Rates)

Pay attention to these things in your insurance contracts

10 Things You Must Pay Attention to in Your Insurance Contracts (Other Than Rates)

ABA Therapy providers have more to think about than just rates when it comes to insurance contracts. This list gives you 10 important details to look for.

While everyone knows that the fee schedule is a critical aspect of a provider’s contract with an insurance company or a managed care organization, other aspects of the contract can make providing services almost as difficult as unsustainable rates.

1. Timely Filing Deadline

Billing for ABA therapy has all kinds of complications that can quickly add up and cause you to miss your timely filing deadline. Some contracts will have standard language with timely filing deadlines as short as 60 days. This is a very difficult deadline to meet be sure to find this requirement in your initial reading of the contract ask for a longer timely filing deadline.

2. Deadline for Appeals

Contracts will also list the amount of time you have to file an appeal or dispute a claim if it is not paid correctly. ABA therapy is still a relatively new niche when it comes to coverage by insurance plans. Claims are often processed incorrectly or denied in error. With a busy practice, you will want ample time to review all of your claims and dispute any that are not correct. Be sure that you ask for a longer timeline for disputes if necessary. Your state may even have laws to assist you in this area. For example, both Arizona and Colorado mandate that all providers have 365 days to dispute incorrectly processed claims.

3. Notice of Material Change

How long does the insurance company have to notify you of material changes? If you are contracted with multiple insurance companies, possibly even multiple states, keeping up with all of the constant changes in policies set by insurance companies can be difficult. Be sure to note how much notice the contract states the insurance company must give you in order to make a material change to your contract. Material changes would include changes to fee schedule or other significant aspects of your services that will affect your financial well-being. Some contracts may try to include notices of only 15-20 days, but this is fairly short for material changes. A reasonable timeline is usually 90 days of notice. Also make sure to notice HOW the insurance plan must notify you. Do they need to send the notice to you in writing? Or, can they simply post material changes on their website or in a newsletter? If you feel you were not appropriately notified of a material change, according to the terms of your contract, you can dispute the change.

4. Disputing a Material Change

In addition to noting how much notice you will get for an amendment that will make a material change to your contract, also note how long you have to reply and dispute the amendment. If you do not want to agree to the changes, then you must appropriately respond to the notice. Make sure you know how many days within which you must respond and how to submit, usually in writing. The insurance company will have to negotiate with you before moving forward with any changes to your contract. Note that this will only be for managed care organizations and not government insurance such as TRICARE or Medicaid.

5. HMO Networks

Research whether or not the insurance company has prominent HMO networks in your area. Some managed care organizations offer a lot of HMO policies, and providers will be out of network unless HMO networks are included in the contract. As families inquire about your services, track which insurance they have and note whether they have a specific HMO policy. When you go to contract with the plan, you will have a better understanding of the local policies and will be knowledgeable to ask about the HMO networks. Or, simply as the provider representative you are working with to include any appropriate HMO policies in your contract.

6. Term of the Contract

A brief section of your contract will state how many years the initial term of the contract will last, and how frequent the contract will renew from that point forward. Common initial terms may be anywhere from 1-3 years. Remember, the contract is binding during this time, and you cannot give notice that you would like to terminate the contract until the initial term is expired. If the initial term is more than 2 years, it may be worthwhile to negotiate this point. If the insurance plan makes amendments to any policies that makes services difficult or unsustainable, you cannot leave the provider network until the term of the contract. A good example of changes not involving rates could be significant credentialing requirement increases, excessive audit expectations, or increased authorization stipulations.

7. Electronic Claims and Payment

Having the ability both to bill and receive payment electronically is becoming a critical aspect of efficient billing practices. Even if your practice is small and you are working toward electronic billing, verifying with the plan that electronic billing is possible will be a great step. Submitting claims electronically is much faster, expedites your payments, and gives you the ability to track everything online both through your system and the plans online portal. Therefore, tracking payment as well as resubmitting or disputing claims also becomes much more effective because information is already logged in the insurance company’s system.

8. Credentialing and Clinical Requirements

If the insurance plan does not list credentialing and clinical requirements in the contract or online, be sure to ask right away. Some over the top requirements in these areas can be deal breakers. The representative handling your contract may not know the answers to your clinical questions, but have a list of questions ready to send so they can get input from other departments. As insurance coverage for ABA therapy has expanded, some plans have started out with unreasonable requirements. If any requirements are out of the “norm” compared to your other contracts, you can ask that they be changed or removed. For example, some plans have included drug testing for staff in credentialing requirements (very expensive to do for a single contract), or others have stated that only licensed providers are able to provide all hours of therapy (obviously not consistent with the practice of ABA). If you sign a contract before catching these types of deal breakers you are locked in for the initial term of the contract!

9. Length of Authorizations

Make sure to include questions about obtaining authorizations in your list of clinical questions. Again if the requirements are more intensive or cumbersome than other plans, you will be doing a lot of extra work for this one contract. You will need to weigh whether the requirements are in line with best practices and worth taking on. A major sticking point could be a plan that wants to issue authorizations in increments less than 6 months. For both clinical and administrative reasons, requesting authorizations more frequent than every 6 months could be setting yourself up for trouble.

10. State Addendums

Many contracts for national insurance companies will have standard language that is sent to every provider, and an additional addendum will have terms specific to the state in which you practice. Be sure to read the addendum carefully to see if any sections of the addendum replace language in the contract. Some critical administrative differences may be included depending on the laws that exist in your state. If you practice in multiple states, then you should have an addendum for each one.

Keep these things in mind and it will help keep you on the right track to quicker payments. Should you have any questions or would like to chat about how ABA Therapy Billing and Insurance Services can help make this process easier, shoot us an email or give us a call at (520) 800-4740.