CARES Act is the Coronavirus Aid, Relief and Economic Security Act appropriated $100 billion with an additional $75 billion appropriated under the Paycheck Protection Program and Health Care Enhancement Act for clinicians.
HHS has subcontracted UnitedHealth Group to distribute the initial $30 billion. The formula CMS is using to calculate provider payment is:
2019 Medicare FFS received (not including Medicare Advantage) DIVIDED by $484,000,000,000 (the total amount of all Medicare FFS reimbursements in 2019) and MULTIPLIED by $30,000,000,000. The money is calculated based on Provider Tax ID, not NPI! Therefore one group practice or hospital with multiple PTAN or NPI numbers will receive one lump payment and must distribute it to practices accordingly.
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.
During the COVID pandemic, payors have issued updated billing guidelines that comply with teletherapy and Telehealth treatments.
It is important to verify both benefits and eligibility as well as billing guidelines with all of your payor’s prior to treating the member.
While the information is changing and should continue to be verified, you may find this cheat sheet for modifiers helpful.
Medicare - 95
Aetna - GT
Cigna - 95
Humana - GT with place of service 02
UHC - GT
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.
Step 1-Obtain an NPI.
Before any form of insurance credentialing is completed, licensed clinicians are required to obtain an NPI (National Provider Identifier) Type I # from nppes.gov.
This number stays with you for life.
The only information that changes is your name if you get married or have a name change, contact information, address, and license information. It also references your primary taxonomy, which is your specialty identified by a numeric format.
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.
You may be out of network with the patient’s plan, however, you may be in-network with the leased network the member’s plan carries. This means you are allowed to see the member in the network! Always look at both sides of the member id card for a leased network logo or name. Additionally, some leased networks are not listed on the member id card, but may be covered through your other contracts such as Three Rivers, Magnacare, Multiplan, and etc. Benefits and eligibility are always required for true benefit coverage, but, remember this tip when speaking with a patient over the phone to schedule an appointment!
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.
When moving from one state to another, always perform a full market analysis and licensing regulation requirements prior to entering that market. This is because some states' operational licensing regulations may drastically differ from others. This applies to the county and state operational regulations as well as the State Licensing Boards for your given specialty. We perform these types of comparative analysis daily and are aware of the operational blockades that may impede your 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.
Your CV must be in chronological order with your most current employer listed at the top. -All information on CV must be matched in CAQH' -List all dates in MM/YYYY format with start and end dates.
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.