The Challenges of Billing Out-of-Network

One of the biggest challenges for an urgent care is billing insurance as a non-participating provider.

When opening a new practice or adding a clinic, completed credentialing and contracting is essential and has a direct impact on the overall success for a new business.  Opening without effective dates may result in cash flow shortages due to the fact that most health plans will not offer retroactive effective dates. Often, it comes down to patient satisfaction: getting patients in the door and securing their return business. Even when your practice is fully credentialed, the challenge continues as you bring on new providers.

Contracting and credentialing remains an archaic process with little oversite to complete processes in a timely manner. A new practice can expect the process to take up to nine to 12 months. With new providers, it can take 90 to 120 days to add them to your contract when full credentialing is required. Full credentialing is when all claims must be billed under the rendering (i.e., face-to-face) provider. Billing under a provider that is not the rendering when full credentialing is required is also the biggest compliance risk in urgent care with multi-million-dollar settlements with the Department of Justice (DOJ) in recent years. With private payers creating similar policies, it is no longer a grey area. Practices risk denial of claims, recoupments, and loss of contracts.

Fee-for-time compensation arrangements (formerly called Locum Tenens) is not an option for physicians as once credentialing starts the physician becomes a member of your group practice. One member of a group practice cannot be a locum to another member of a group practice.

For non-physician practitioners (NPP), billing services under the incident-to guidelines is also not an option. Incident-to is for practices where the patient’s condition requires follow up.  It is not for patients with new problems, which is almost all of what is seen in the urgent care setting. Even in the case of longitudinal care, incident-to billing is not an option as often as the industry would lead practices to believe. Once a treatment plan changes (i.e., changing the dosage of a medication), it is no longer an incident-to service.

Generally, out-of-network claims process in one of three ways:

1. Claim will pay to the patient: When this occurs, a payment is made to the patient directly from the payer. This does not guarantee that the practice will eventually get the payment.
2. Claim will process towards the patient deductible: This only occurs when the patient has out-of-network coverage.
3. Claim will fully deny as out of network: Not all patients will have OON coverage and they may be responsible for the full bill.

Asking the patient to pay cash at the time of the visit is not an ideal option. Even with excellent care, often patient satisfaction can come down to the amount of the bill. This option will cause delays in the ability to become profitable due to lower patient volumes.

Recommendations for Minimizing These Problems

Start the contracting process at the beginning of your project to avoid delays. Do not wait until you are ready to open the doors. Once your business opens, your expenses go up. Heather Real, a senior consultant at Experity, recommends having 75-85% of your credentialing completed prior to opening.

Require new hires to provide all the information required for credentialing during the onboarding process. The new hire should not start until all necessary items are received. The credentialing process cannot start until this information is obtained.

In the case of one non-participating provider when multiple providers are available, train your front staff to direct patients to the in-network provider.

Make sure the patient knows that they are seeing a non-participating provider and that they may be responsible for a large portion of the bill. This should be done prior to rendering services so the patient can make an educated decision about their healthcare. Kim Hardin, a senior vice president of RCM operations at Experity, recommends obtaining a credit card on file and/or collecting payment at the time of service when the practice is non-par with the patient’s insurance plan.

Share with your customer service team if they can offer a discount to the patient should they call. This can be tricky as well. Be sure to check with your healthcare attorney to set up a policy that is compliant with all state and federal laws.

Bottomline, the best option for reducing these challenges is planning.

Flu Season Refresher

August is the start of another flu season. Here are some tips to help with coding and billing:

• Vaccinations claims are billed with two CPT® codes: one for the vaccine and one for the administration of the vaccine.
• The exception is if the practice did not pay for the vaccine. In that case, only the CPT® code for the administration of the vaccine is reported. When the vaccines are supplied by a Vaccine for Children Program (VFC), how the administration of the vaccine is reported will vary by State Medicaid carrier.
• Last year there were nine different codes to report the vaccine product. It’s important to use the correct code for the vaccine used by your practice (e.g., Fluzone).
• Administration of the vaccine is reported with CPT® code 90471 for injections. HCPCS code G0008, (Administration of influenza virus vaccine) is used for Medicare, instead of a CPT® code for the administration. Use CPT® 90473 to report administration of vaccines by an intranasal or oral route. If injections include counseling for patients up to and including age 18, see CPT® code 90460.
• All vaccines are reported with diagnosis code Z23 (Encounter for immunization).
• An office visit should not be reported when the sole reason for the visit is a vaccine. These patients do not need to see a provider.
• Case rate plans often exclude routine services including immunizations from the contract. It’s important to know your contracts as vaccines for patients with these plans should be cash pay. Patients should be notified before services are performed.

Experity recommends you share the coding details with your billing team, so the correct codes are reported.

Industry Notes

New York: Medicaid Waives Timely Filing

Due to the cybersecurity incident that occurred with Change Healthcare/Optum on February 21, 2024, New York Medicaid has instructed that claims that exceed the timely filing limits may be submitted electronically using Delay Reason 15 (Natural Disaster). There is no additional documentation required to use Delay Reason 15; however, where particular claims require documentation, such as invoices for pricing, the claim and all necessary documentation should be submitted as a paper claim along with the delay reason form indicating Delay Reason 15. Providers should also maintain documentation that supports being affected by this incident.

Claims must be submitted by August 30, 2024, to be considered for payment. Claims that are payable using Delay Reason 15 are all claims that couldn’t be submitted timely due to the Change Healthcare/Optum cybersecurity incident only. Submitting claims that do not meet this purpose with Delay Reason 15 is not permitted and may be considered Medicaid fraud subject to review by the Office of the Medicaid Inspector General.

Claims for this incident submitted after August 30, 2024, with Delay Reason 15 will be denied.

Example Claim Submission:

Oklahoma: HealthChoice EGID Transitions to OHCA

Due to recent legislation, the Employees Group Insurance Division (EGID) is transitioning from the Office of Management of Enterprise Services (OMES) to the Oklahoma Health Care Authority (OHCA), effective July 1, 2024.

HealthChoice plans will continue to be administered by EGID without disruption to any network providers. HealthChoice fee schedules, website, claims administrator, provider portals and payment vendor will continue to be used. Processes for contracts, applications, provider rosters and provider updates will remain the same.

UHC APWU Insurance Updates

Starting Jan. 1, 2024, American Postal Workers Union Health Plan (APWUHP) High Option members use the UnitedHealthcare network.

Submit electronic claims with the following payer IDs:

• Medical claims: Use Payer ID 39026
• Secondary medical/dental claims: Use Payer ID 44444

The address for paper primary claims is P.O. Box 30783, Salt Lake City, UT 84130-0783. For secondary claims, use P.O. Box 1358, Glen Burnie, MD 21060.

Members were issued new cards with the UnitedHealthcare logo.

OWCP Adjustment/Void Processing for DFEC and DCMWC

Effective June 1, 2024, the Office of Workers’ Compensation Programs (OWCP) will implement updates for adjustment/void processing.

For the Division of Federal Employees’ Compensation (DFEC), providers will no longer be allowed to submit bill void transactions. Providers wishing to return funds have the option to mail the refund along with an Adjustment Request template as the coversheet.

For the Division of Coal Mine Workers’ Compensation (DCMWC), providers will have the new option to submit bill adjustments via the WCMBP portal.

For the Division of Energy Employees Occupational Illness Compensation (DEEOIC), there is no change in the current process for adjustment requests.

Louisiana: Updated Medicaid Fee Schedule – Aetna Better Health

Effective May 1, 2024, Louisiana Department of Health (LDH) updated the Louisiana Medicaid Fee Schedule to reflect a number of changes in coverage.

The below codes were removed from the Laboratory and Radiology Fee Schedule. For claims with dates of service on or after 5/1/2024, the codes will be covered only if performed in a (UB-04) facility, observation and/or inpatient setting and will not be covered in an outpatient setting:

• 0202U
• 0223U
• 0224U
• 0225U
• 0226U
• 0240U
• 0241U

Aetna Better Health of Louisiana will have their system updated to reflect these changes by June 21, 2024. Claims for these services between May 1^st and June 21^st will be re-processed by July 6, 2024.

Texas: Molina Healthcare Provider Access and Availability Standards

Molina Healthcare requires that the following appointment availability schedule be followed by network providers,

• Urgent Care should be received within 24 hours of request,
• Emergency Care should be received immediately,
• Routine exams should be provided within 14 days of request,
• Preventive health services for children under 6 months of age should be provided within 14 days.
• Preventive health services for children ages 6 months through 20 years should be provided within 60 days.
• Preventive health services for adults should be provided within 90 days.
• Texas Health steps should be provided according to the Periodicity Schedule located at https://www.txhealthsteps.com/tools-resources.

Contracted Primary Care Providers (PCP) must ensure that they, or another qualified medical professional, will be available or accessible to members 24 hours a day, 7 days a week. Acceptable after-hours coverage includes:

• An office telephone answered after hours by an answering service, which can contact the PCP or another designated medical practitioner. Calls must be returned within 30 minutes.
• An office telephone answered after normal business hours by a recording in at least English and Spanish, directing the patient to call another number to reach the PCP or another designated provider. Someone must be available to answer the designated provider’s phone. A second recording is not acceptable.
• An office telephone transferred after office hours to another location where someone will answer the telephone and be able to contact the PCP or another designated provider. Calls must be returned within 30 minutes.