Insurance workflow

[Candidate2017]

I feel I have a good grasp of how to run a front office from my residency clinic. However insurance operations are a black box to me as I prepare to transition to starting a practice. As I understand it, insurance workflow looks like this:

-Prospective patient applies for intake.
-Call insurance to verify insurance benefits, copay, deductibles. How long does this take?
-See patient.
-Collect copay.
-Submit bill to insurance. Is this done via EMR, third party biller, or inhouse?
-Insurance communicates denial or adjustment.
-Contact insurance to appeal. How is this done? How long does it take?
-Insurance does EFT or sends check. How long does this take?
-Bill the patient for the balance. Is there software to track this, or part of the EMR? How is aging and collections done?

Are there points that can be automated/integrated by EMR or other means? Is a third party biller required? Which points in the workflow cause the most issues or take the most time?

Would it be feasible to do all this myself, at least at the start? What about hiring a part time biller?

---

Members don't see this ad.

 

[Sushirolls]

There can definitely be variability in this flow.

INTAKE
A few other threads on here as to what this looks like. Doctor field the call? assistant field the call? paperwork first? Screen questions or questionnaire first? So many things. Then to also consider the medical legal aspect if you are doing it, did you cross the line into establishing the relationship?

BENEFITS/ELGIBILITY
Could punt 100% to patient, with disclaimers it is their responsibility - but you run the risk of of dissastified patients who didn't do this and then get a big bill from you. This is quick, and typically a website portal to the insurance company that you enter certain details ranging from insurance ID number to name to DOB and you find out if in network or not. Some ClearingHouse programs (like ApexEDI within Luminello EMR) have the abilit to also look up elgibility for patients. This is tricky and not always easy to read how the insurance companies define it because ... drum roll... we're Psych... and things in psych are much more complex. I've charged patients X dollars for their listed copay, only to learn after the insurance processed the claim, nope, its actually Y dollars.

COPAY
Try to collect this upfront, but easier said than done, as relies upon your ability to understand the above benefits/elgibility. I'm still bad at this, and with Covid copay changes, just waiting until later to find out the copay and collect it then. The more you collect up front... Well the more you actually collect.

CLAIM SUBMISSION
Don't bother with 3rd party billers. Use the integrated clearing house connected with your EMR. Choose EMR that has an integrated clearing house. Luminello for instance does. Look at the prices for this for various companies. Luminello is very well priced, other companies like Athena will be looking for a percentage of billings... don't do percentage.... only do fixed cost claim submissions. You submit X claims, you get charged Y amount. You will finish your note, then go 'click, click' and submit to insurance company thru the integration of this ClearingHouse with your EMR. You will eventually get back a paper EOB statment and a paper check. In order to get away from paper EOBs and paper checks you need ask the ClearingHouse folks, "how do I sign up for EFT/ERA enrollment?" EOB= statement patients get explaining the insurance claim, ERA is the barebones electronic version packaged thru ClearingHouses. EFT is the electronic found transfer, i.e. the insurance company pays you directly into a bank account of your choosing. EFT/ERA can be a pain to get started, but is so worth it in the end, and makes things seamless. You and (your assistant?) will follow up on the status of the claims within your EMR, and less so go to the specific isnurance company websites to find it specifically in their section of "claims look up". Checks, because paper take as long as they take so ~4-12 weeks. EFT can be as fast as 1 week, or longer. These days I'm getting most EFT payments in 2-4 weeks, and Medicare in 6 weeks.

APPEALS
I've not done any in almost 2 years. Routine outpatient Psychiatry, not likely needed.

PATIENT RESPONSIBILITY (PR)
Will come back thru the paper EOB, or as you astutely signed up for, ERA enrollment (i.e. the insurance company sends the EOB data as an ERA to your EMR and then *poof* it shows up nicely in your billing section of the EMR). Paper EOB you need to manually key in all these numbers into the patient billing component of your EMR portal. Then you need to generate some kind of paper or electronic bill to send to your patient. Most EMRs will have built in tool to send them electronically thru the portal, or make a nice neat form you can print and then snail mail. Having ERA enrollment, saves you (and your assistant?) this data entry step. Collect payment how you determine, cash/check/card/bitcoin/goat milk/etc. Each EMR has a different approach to following the life cycle, or aging of accounts. I'm happy with my Luminello setup. There are companies with more bells and whistles for sure, but IMO, do you really need them?


*it is, and I recommend, that you do this all your self. Maybe hire an assistant where some of this is their responsitibility.
*do not hire a 3rd party biller
*Choose your EMR wisely
*Biggest time sucks are choosing wrong EMR, or not having ERA/EFT enrollments. Or doing things clinically that require Prior Authorizations or are prone to rejections/denials.

 

[Alemo]

Thanks for the response sushirolls. Your posts have been a beacon of “you can do it” in the murky ocean of career “prospects” urging us to Do Your Part For The Empire Your Community Health System.
How is medication coverage made known to everyone early in the process? Does Luminello have integrated data on coverage? It seems like that could be a costly run-around if every other patient is calling back in a few days complaining of drug costs.

 

[Sushirolls]

Thanks for the response sushirolls. Your posts have been a beacon of “you can do it” in the murky ocean of career “prospects” urging us to Do Your Part For The Empire Your Community Health System.
How is medication coverage made known to everyone early in the process? Does Luminello have integrated data on coverage? It seems like that could be a costly run-around if every other patient is calling back in a few days complaining of drug costs.

Insured patients have pharmacy benefits, in other words their meds are covered. Typically in residency we learn which meds are generic and what their price points are relatively speaking. So avoid the newer non-generic meds, and those that are in general more expensive. Clinically I am able to assist patients with results by using cheaper generics. The only times I seem to run into expensive non-generic meds are when I have a transfer of care for a patient who comes to me from an ARNP - Vraylar, Saphris, Rexulti have been the top offenders.

The integrated prescribing feature with Luminello is now DrFirst, and they do have all sorts of cost/insurance formulary comments integrated into it - but honestly I've ignored them, because I already know them from years of trial and error hard learning. When weird formulary coverage issues happen, point people to Costco if your metro has one, as they typically have the lowest cash pay prices for meds. And/Or point them to GoodRx.com where you can readily see the price of the meds and their discounts with their free to print coupons.

In the past almost 2 years of my practice, I've had 3-4 patients call back with price concerns on meds, because for whatever reason their insurance company wouldn't cover, but with GoodRx and +/- CostCo, problem solved.

 

[clausewitz2]

Insured patients have pharmacy benefits, in other words their meds are covered. Typically in residency we learn which meds are generic and what their price points are relatively speaking. So avoid the newer non-generic meds, and those that are in general more expensive. Clinically I am able to assist patients with results by using cheaper generics. The only times I seem to run into expensive non-generic meds are when I have a transfer of care for a patient who comes to me from an ARNP - Vraylar, Saphris, Rexulti have been the top offenders.

The integrated prescribing feature with Luminello is now DrFirst, and they do have all sorts of cost/insurance formulary comments integrated into it - but honestly I've ignored them, because I already know them from years of trial and error hard learning. When weird formulary coverage issues happen, point people to Costco if your metro has one, as they typically have the lowest cash pay prices for meds. And/Or point them to GoodRx.com where you can readily see the price of the meds and their discounts with their free to print coupons.

In the past almost 2 years of my practice, I've had 3-4 patients call back with price concerns on meds, because for whatever reason their insurance company wouldn't cover, but with GoodRx and +/- CostCo, problem solved.

Do you literally just refuse to do prior auths when insurance companies initially decline to cover it?

 

[Candidate2017]

Thanks for the response sushirolls. Your posts have been a beacon of “you can do it” in the murky ocean of career “prospects” urging us to Do Your Part For The Empire Your Community Health System.
How is medication coverage made known to everyone early in the process? Does Luminello have integrated data on coverage? It seems like that could be a costly run-around if every other patient is calling back in a few days complaining of drug costs.

Any drug that's advertised on TV or in print is not a generic drug and will likely be costly. I've only had to do a couple prior auths because I try to avoid extra administrative work like the plague. You shouldn't be dealing with many prior auths unless you work in an area like treatment resistant depression, private insurance schizophrenia, or get lots of patients from PCPs. PCPs love to sprinkle whatever latest, greatest, costliest psych med pushed by the pharm rep before punting to psych.

 

[Candidate2017]

*it is, and I recommend, that you do this all your self. Maybe hire an assistant where some of this is their responsitibility.
*do not hire a 3rd party biller
*Choose your EMR wisely
*Biggest time sucks are choosing wrong EMR, or not having ERA/EFT enrollments. Or doing things clinically that require Prior Authorizations or are prone to rejections/denials.

Thanks this is helpful. I plan on doing this all myself. at least at the beginning, so I can understand where I can optimize efficiency or how I can train someone.

So mainly choosing an EMR that can integrate claims submissions and ERA/EFT. Any thoughts of Luminello vs ICANotes, in terms of integration and billing, as well as ease of use, bang for the buck, future expansion?

I think in another thread @randomdoc1 mentioned verifying benefits and upfront collection of copay/deductible/co-insurance. That's a good idea to devote time to that. A bill paid upfront is a bill not unpaid.

 

[clausewitz2]

Any drug that's advertised on TV or in print is not a generic drug and will likely be costly. I've only had to do a couple prior auths because I try to avoid extra administrative work like the plague. You shouldn't be dealing with many prior auths unless you work in an area like treatment resistant depression, private insurance schizophrenia, or get lots of patients from PCPs. PCPs love to sprinkle whatever latest, greatest, costliest psych med pushed by the pharm rep before punting to psych.

I treat a lot of OCD. You'd be surprised how many insurance companies have chosen 400 mg a day of sertraline as the hill they wish to die on. Also if you are not afraid of stimulants and treat very clear, well-established ADHD in adults with the most well supported available medication, get ready for incredibly arbitrary demands for documentation and strange formulary nuances that vary from payer to payer and year to year.

 

[Sushirolls]

So mainly choosing an EMR that can integrate claims submissions and ERA/EFT. Any thoughts of Luminello vs ICANotes, in terms of integration and billing, as well as ease of use, bang for the buck, future expansion?

I have a Luminello sign in my front lawn, might need to talk to some one who has an ICANotes sign in their lawn. Or better yet, test them out yourself make a pros/cons spreadsheet and try make the most informed decision for you.