2 MINUTE VIDEOS THAT HELP RUN A SUCCESSFUL PRIVATE PRACTICE

This week’s tip is for you to check the #MedicareAdvantage #Payors available in your region and check your #enrollment with them. While eligible beneficiaries can enroll in a #MedicareAdvantagePlan once first eligible for #Medicare (65 years old), Medicare beneficiaries are also welcome to enroll during the annual Medicare #openenrollment period between October 15 through December 7.  Per their website, #CMS has proposed that in 2021 premiums will be the lowest in 14 years and that they have decrease by 34.2% since 2017 allowing enrollment into Medicare Advantage (Medicare Part C) expected to increase by 10% for 2021 from 2020. In context, in 2020, an estimated 4 out of every 10 Medicare #Beneficiaries were enrolled in #PartC.  How does this affect your practice? If you treat A geriatric population, it may be in your best interest to review your #providerenrollment with the Medicare Advantage players in your region. 

#Optum is a #healthinsurance administrator of #mentalhealth benefits for #UnitedHealthGroup. It covers a wide range of mental health benefits for its members. When a #provider is #contracted with #Optum Health, they are also able to treat members who may have additional insurances outside of United Healthcare. These may include employer-sponsored and individual plans from #AetnaHealthPlan, Blue Shield of California, #CIGNA, as well as #MedicareAdvantage plans with #Humana and #Wellcare. It's important to note that these are just some of the products and plans that Optum covers.   

Here are 3  ways to truly understand how a member's benefits will be administered: 

1️⃣ Always read the contract and understand which plans and products are covered. This is typically where there is an opportunity to negotiate or #renegotiate for additional coverage plans or to remove products provider does not want to take. 

2️⃣ Always #verify #benefitsandeligibility prior to scheduling a patient's appointment 

3️⃣ Always check out the plans and products that the payor covers on their home website. For Optum, this information is available at here. 

Even before COVID accelerated the #Telehealth practice, some states already had legislature in place that accepted and welcomed out of state licensed professionals as long as the clinician had an equal independent licensure in their home state and completed the appropriate documentation.  

In 2019, Florida passed Chapter 2019-137, Laws of Florida, which authorized out-of-State health care practitioners to perform Telehealth services for patients in Florida.   Rather than submitting a full-on application with the appropriate licensing board, the new process calls for the submission of 4 documents, including Application for Telehealth Provider Registration.  

Your Medicaid enrollment may significantly impact your practice amidst the COVID pandemic.  In an effort to limit the exposure of COVID-19, 1135 waiver has temporarily relaxed the regulatory compliance on HIPAA privacy rules and teletherapy regulations.   

However, due to the staggering increase of unemployment claims, provider practices may face additional changes to their patient access stemming from insurance panels.   Check out this blog https://mkmedicalsolutions.com/blog/f/how-does-covid-affect-your-practice  for more information. It is helpful for all licensed specialties in all states.   

How do I become a Medicaid provider? If I am a Medicaid participating provider, does that mean I can start seeing patients on the Medicaid Managed Plans? Do panels close?  - These are just some of the most common questions we receive regarding Medicaid enrollment.   

More and more states are outsourcing the management of Medicaid covered lives to Medicaid Managed Plan Programs from Health Insurance Companies.   

If you choose to be a Medicaid participating provider, then obtaining your Medicaid provider number from the state is the first step. The second is becoming contracted with the Medicaid Managed Programs or health insurance companies who offer Medicaid in your county/region. The names of the Medicaid advantage programs can be found on your State's official Medicaid website. 

However, sometimes panels become closed and providers are not able to get onto the plans. Don't get discouraged, we can help!

Step 3: Obtain a Type II NPI and a Group Agreement with payors. 

From an operational perspective, it is better to obtain a group contract rather than an individual agreement. First, the group agreement will be under an entity name, group TIN, and a Type II NPI (group). Groups have strength in numbers, whereas payors will negotiate more with a group rather than an individual single provider. Once a new provider joins a group, it takes usually less time for the credentialing and contracting process rather if the individual provider would go through the process solo.  Groups also have better benefits for group discounts such as those for employee health insurance, vendor agreement management, and professional liability insurance coverage. Be wary of exceptions that may prevent you from forming a group such as regulatory compliance standards of your state or the payor itself. For example, some states or payors prevent the formation of a group unless there are 5 clinicians

Step 2 - obtain a CAQH number. 

CAQH is the Counsel For Affordable Quality Healthcare, a nonprofit organization that holds a free to the clinician/provider/healthcare professional database of their professional and personal history. Stored information includes maiden name, ss#, DOB, address, licenses, professional liability history and actions, employment history, and much more. 

This database is utilized by Health Insurance Payors to complete credentialing and provider enrollment into health plans.  Each individual with a CAQH profile is issued a unique numeric CAQH provider number that is utilized by payors during credentialing and provider updates.

 A charge master is your practice reimbursement rates received from both payors and patients for the services rendered to your patients, as well as the fees for DME and RX!   When rates change due to Payor contract updates or economic impact such as natural disasters, the impact on your practice will be significant if you don’t have one specified listing of your expected account receivables. The charge master also helps your RCM, billing, and accounting teams to maintain a clear line of sight as to true losses or gains.  

Regardless of how many TIN your practice has, the patient place of service and unique patient account number can be utilized for financial integrity reporting.   RCM operations include various points from patient entry to billing to payments.  How you run your RCM will impact your overall picture of the practice. Utilize all of your RCM reporting tools to your advantage to get a better understanding of your practice.  

CMS's Third Online Directory Review Report audit found that between 2017-2018, 48.74% of online directories had inconsistencies such as provider not being at the location, incorrect phone numbers, or providers accepting new patients.   These findings are a direct access barrier to your potential patients whereas they won't be able to find you and the online directories may have incorrect demographic records which result in denied claims.   Remember to review your online directories quarterly for all of your payors, make needed changes in your CAQH account, reattest, and always notify the payor with any demographic updates.  

Digital transformation is the overall encompassing of people, processes, mindset, and analyzation of technological and digital processes of your practice.   

When examining your technological improvement, look at the way your practice interacts with patients, payors, regulators, and your overall communication and processes. If there is no significant change within the past 5-15 years, then your digital transformation should improve.    Digital transformation in the healthcare industry is often overlooked because of the fear of cultural and workflow change. However, as in other industries, technology is advancing customer service and operations, your practice too can significantly improve with digital implementation.  

Congratulations, you finally received an approval from a Payor! So you can start seeing patients right? Unfortunately not yet.  If the letter is only advising you of a credentialing approval and not contracting, then you must wait until you get confirmation that your contract has been loaded. Typically, that takes another 15-45 business days. Be in communication with network account management or provider relations you follow up on the status.

When going through the credentialing process with private payors, if you do not yet have your Medicaid and Medicare #s issued, then in your CAQH account, input pending in the respective fields of Medicaid & Medicare instead of leaving the fields blank.

The billing address is where your payment goes.  Be sure to upload the W9 into your CAQH attachments and that the billing/payment information in your practice location matches the W9.