Outsourcing Billing and Insurance Services–Setting Expectations

Outsourcing Billing and Insurance Services–Setting Expectations

How do you know if you or your company really needs to outsource your ABA Billing and Insurance Services?

Consider these 4 choices you have when it comes to the necessary business processes of billing and collections, credentialing and contracting, benefits and authorizations:

  • Become an expert and do it yourself!
  • Hire someone in-house with experience!
  • Outsource to a company with experience!
  • A combination of the above!

Which of these is the best fit for you? In this blog, we are going to go through some things to think about in setting expectations and evaluating your decision in 3 categories of back office functions. I will also share some of our learning experiences in setting expectations in each of these areas. And don’t forget, we now provide monthly Webinars to share as much as we can with providers with relation to these process steps for ABA Billing and Insurance Services.

Billing and Collections

Setting Expectations: Consider that there is more to billing insurance properly than you may realize. At a minimum, you need to know the basics of how to complete a CMS 1500 Claim form. Best practice is to use a practice management software. Be prepared for insurance payments not to come in quickly, it can take up to 45 days with some funders and with issues, even longer. There are myriad reasons that denials occur. Payments for services relate back to contracting, benefit checks and authorizations. Timely filing and corrected claim timely filing deadlines are important to follow. Follow up processes are critical to success.

Our Story: I joke with our team that when we started helping providers with billing and collections, I used to accept timekeeping on a paper napkin. Through experience, though, we have learned the value of a good practice management software and have designed best practice tips for our providers to maximize reimbursement. Staying connected with the issues in the industry is key and is why we follow Autism Speaks, APBA, and work closely with an attorney that specializes in ABA.

  • You can do your own Billing and Collections if you take a class or study how to prepare medical claims properly. You can learn how to do so in your practice management software or using online portals per insurance company. You will want to review your remits from payments on a weekly basis and set up a system to track payments against claims or post to your practice management software to produce patient statements and track dates that need follow up.
  • You can also hire in house help to complete the process and follow through on the tasks and procedures you put in place. Keep in mind it takes more than just medical billing knowledge. We have had many medical billers that we have interviewed or worked with us for a short time that could not make the transition for learning the complexity of ABA.
  • You can outsource to a company that is experienced in ABA Billing and Collections who you will pay to provide the service for you. Same recommendations as above in picking a service company that understands ABA. Standard medical billing companies will not understand the complexity of the necessary follow up for payment issues related to ABA.
  • Or you can decide to do some on your own and some outsourced or hire help, a combination that works for you based on the value of your time and expectations.

Note: Some agencies will keep their private pay, school district contracts, regional centers and even sometimes Medicaid in house and just outsource private insurance.

Biggest Pro for Outsourcing Billing and Collections: Someone other than you keeps up with the code changes, billing requirements and insurance nuances, and the endless follow up with insurance companies who don’t pay as they should.

Credentialing and Contracting

Setting Expectations: You must be prepared to wait a substantial amount of time for the process to be 100% complete. If you are banking on being an in-network provider to start your business, you need to set your start-up date expectations out 6 – 12 months from the start of the process. Be prepared that despite doing everything right the first time around, you may have to do it again. Do not be shocked at the rates that you are offered from insurance companies and always negotiate to the best of your ability. Unfortunately, there is not much motivation from insurance companies to efficiently expedite contracts for in-network providers.

Our Story: When we first started this company and the Facebook page, there were several new providers that needed help with credentialing and contracting. To the degree that at various points over the years, we have had a wait list for this service and had to refer out to our friend, Sarah Schmitz, from Comprehensive Billing Consultants, who shares the same values we do in providing services to clients. I had high hopes when starting down the path of helping providers with this service–perhaps a bit naïve in thinking that if we prepared the documentation accurately, sent in applications in an organized manner, and followed up frequently that we could actually beat the odds and have a faster turnaround. I wanted to see these providers be able to help as many clients as possible and quickly learned that this would not happen overnight, or even in three to six months at times.

  • You can certainly do Credentialing and Contracting on your own. Complete your CAQH and start researching the process for each insurance company you would like to contract with. Understand the difference between group and individual contracts and that it’s a 2-part process. Credentialing and Contracting are separate. Purchase a simple Adobe or Foxit license to complete and sign forms online and/or an electronic fax or computer printer/scanner/fax. Set yourself a follow up schedule to reach out and check in on the progress. Organize your records and be prepared to duplicate forms previously sent. Read contracts thoroughly and negotiate the rates sent to you from insurance companies as they relate to the value of your services being performed. Prepare to wait!
  • You can also hire in house help to complete the same processes and report back to you on progress keeping your original expectations in mind.
  • You can outsource to a company that is experienced in ABA Credentialing and Contracting who you will pay to provide the service for you if you currently do not have the time to take away from your billable Clinical hours or the budget to hire in house. Be careful in choosing a credentialing service from sources that have primarily worked with medical credentialing. Behavior Health is completely different than standard medical credentialing and contracting, especially ABA which has its own set of codes and rates.
  • Or you can decide to do some on your own and some outsourced or hire help, a combination that works for you based on the value of your time and expectations.

Note: We recommend that if you are working for an agency and want to start a company of your own that you meet with a Business Consultant, an Accountant and a Healthcare Attorney familiar with ABA and that you set a reasonable timeline to have a successful transition. You can have more than one practice location on your CAQH.

Biggest Pro for Outsourcing Credentialing and Contracting: Someone other than you takes care of the continuous follow up, organizes the process, and keeps the ball rolling with the insurance companies.

Benefits and Authorizations

Setting Expectations: You must be prepared that you can get false positives or negatives in your eligibility/benefit checks. Plan to always talk to a live person and to sometimes need to call more than once. You cannot depend on the online portal benefit information only. Never trust if you are told that you do not need authorization for ABA. Try not to be disappointed when a family does not have ABA coverage and have resources available to refer them to, such as, the Autism Speaks Self-Funded Employer Kit. Be clear in your requests for service authorizations, cover all levels of service and locations. Never accept fewer hours without a denial in writing to allow the family to appeal based upon medical necessity. Plan to have the treatment plans for the next auth period completed and submitted up to 2 weeks prior to expiration to avoid gaps in auths and reimbursement.

Our Story: When we first started offering this service, I never anticipated that it literally could take several hours to get accurate information for one eligibility check nor did I expect that I could get a different answer after calling up to three times. I now consult others to be prepared for this and to question anything that sounds fishy. Once we started seeing the same plans over and over, we knew when something didn’t seem right. We have watched the plans over the years start to deny medically necessary treatment for families and have sought out resources and recommendations for providers in the industry to fight against this practice. We learned the value of a good practice management software that can track the authorization utilization and expiration dates. We work to remind providers we complete case management services for of these upcoming expirations. Despite providers asking families to notify of insurance changes, we find it best practice to call at the start of each calendar year to re-check benefits for any changes. If you are working with Medicaid, coverage can be dropped monthly, but typical private insurance will primarily be accurate through the end of the policy period.

  • You can do your own Benefit Checks and Authorizations if you have the time to do so. Set up a task list for the Intake process to ensure complete documentation on a new and use a practice management system for tracking auth expirations or set up a manual tracking system. Determine how to maintain client files that contain the necessary information to pass an audit. You will find that some of the insurance plans do live reviews so if you are the lead BCBA on the case, you will be involved in the authorization process.
  • You can also hire in house help to complete the process and follow through on the tasks and procedures you put in place.
  • You can outsource to a company that is experienced in ABA Benefit Checks and Authorizations who you will pay to provide the service for you. Same recommendations as above in picking a service company that understands ABA. Standard medical billing companies will not understand the complexity of the authorizations for services of ABA or the questions to ask for an accurate eligibility check.
  • Or you can decide to do some on your own and some outsourced or hire help, a combination that works for you based on the value of your time and expectations.

Note: If you have a solid in-house process for benefits and authorizations, this is an area that can be comfortably coupled with outsourced billing. If both functions are kept in-house, I would caution against having the same person do both authorizations and billing. Having these responsibilities separated will provide the ability to have checks and balances, cross training and ample time for follow up to allow focus on problem areas.

Biggest Pro for Outsourcing Benefits and Authorizations: Someone other than you gets to spend the endless hours on the phone getting accurate information and understanding how to maximize your authorization request per your medically necessary treatment plan and the codes allowed by payors.

 

Whichever option you choose, keep in mind that you can vary the decision based on your own needs—and when your needs change, you can choose a different option. Keep the lines of communication open with your in-house or outsourced team. Have patience and set your expectations appropriately. In the end, a collaborative team that is working together to get reimbursement for the important medically necessary services you are providing equals success!

If you have any questions about our services or would like to schedule a consult with ABA Therapy Billing and Insurance Services to see how we can be your outsourcing partner in the way that benefits your agency the most, call us at (520) 800-4740 or use our contact or prospective client forms today.

1 Comment
  • Medwave Billing

    August 20, 2018 at 9:05 am Reply

    Great information and quite credible, in my opinion. I love the parts about setting the correct expectations.

    “You must be prepared to wait a substantial amount of time for the process to be 100% complete. If you are banking on being an in-network provider to start your business, you need to set your start-up date expectations out 6 – 12 months from the start of the process.”

    Become an expert and do it yourself!
    Hire someone in-house with experience!
    Outsource to a company with experience!
    A combination of the above!

    It’s interesting that mention a combination of the above, as I feel this is becoming more common.

    Cheers!

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