July 2013

Insurance & Billing

By Dayna Beddick, M.Ed., BCBA with Leasha Barry, BCBA-D

The joy of health insurance coverage for ABA therapy for people with Autism is often overshadowed by a crash course in the complicated labyrinth of medical billing for providers and costly co-pays and deductibles for families. Most BCBAs do not have experience in medical billing and oft are confused with the complex policy and procedures that differ between insurance providers and even between individual service policies through the same provider.

The first stumbling block to insurance billing is understanding which CPT code to use. These elusive 5 digit codes produce reimbursement for different activities that BCBAs perform. Because there is not yet a universal code for Applied Behavior Analysis, these billing codes differ across insurance providers. It is critical to know which code an insurance provider recognizes, as well as which codes within a particular insurance company operationally define the specific services the BCBA provides.

Once appropriate codes are established between you and an insurance provider. What do we do with them? We will examine a few little known considerations for beginner billers here:
 



How do I establish a rate for service? 

No two insurance companies are alike. They all pay different amounts for different services and different CPT codes. However, it is up to the practitioner to set their rate for services and bill everyone the same amount, regardless of the differing maximum allowed amounts that vary by insurance company. Any infraction of this falls under a false claims statute, violating contracts and the law. As BCBAs learn about medical insurance billing, we look to the medical field and existing medical practices to know how to navigate such issues. As a general practice, it is best ethical practice to establish a published rate for a service and charge everyone the same amount without exception. Often, a providers published rate for service is set above the maximum allowable rates published by insurance companies. Please note, the published rate for service is not expected to be received, adding to the complexity of insurance billing. Expected reimbursement amounts will vary between companies and individual client policies.


What about clients that do not have medical health insurance? May I offer a cash discount?

In January, this issue will likely change along with the institution of national healthcare. For the time being, refer to your local and state law and any existing contracts you have with insurance providers to be sure you are permitted to offer cash discounts to those without medical coverage. If you establish that it is within your right to do so, the Department of Health and Human Services Office of the Inspector General established a general guideline of a 20% allowance. Again, this can vary from state to state and is subject to new laws or specific contracts with private companies.


What about sliding scales for those with low incomes? 

A sliding scale can be used in some instances. The US Department of Health and Human Services (HHS) outlines poverty guidelines yearly at: http://aspe.hhs.gov/poverty/index.cfm, along with federal recommendations for establishing and following the scales. However, please note that the HHS allows state and local governments to establish local poverty rates, so once again, the provider is left investigating state and local law. Once the laws are understood, the BCBA must then reference their existing contracts to ensure sliding scales are in compliance with that contract. This strict schedule for sliding scales is to establish a fair reduced fee based on objective numbers, not by the emotions tied to each individual financial situation.


What about waiving co-pays?

Co-pays are part of the contract in which the insured person agrees to participate in their own care. Waiving or ignoring co-pays violates the contract and may result in the insurance company terminating the providers contract and any other penalties available to the insurer under their contract and applicable law. 


What exactly can I bill under CPT codes?

Most intervention codes are related to 1:1 supervision or 1:1 services with a client. While some companies may offer a special code that enables you to bill for paperwork (e.g., graphing, BIPs, monthly summaries, etc.), please be aware that the allotted hours are different and the rate may also be adjusted. For those companies that do not allot time for paperwork, you can neither bill for ABA after the child is gone nor can you work on paperwork during scheduled therapy. This is considered billing for services not actually performed or upcoding, respectively. For example, consider past experiences with a family doctor. Patients are billed for the visit, but there is much work required after you leave. Physicians may have to pay individuals to transcribe their notes, bill their services, and maintain the patient chart. But recall, they only bill the insurance company when the patient is present. Remember, It is important to know the operational definition of each CPT code by each insurance company you are billing. 


What about cost sharing through group practice?

Some BCBAs are drawn to the higher pay rate when working as in individual rather than accepting a lower pay rate as part of a group practice. However, the higher wage covers all of those indirect costs associated with running a business, including billing. Many BCBAs are following the model of medical group practice instead. Joining forces under a group practice with shared expenses and employees dedicated to understanding the nuances of insurance billing is a useful choice, enabling the BCBA to focus on Applied Behavior Analysis rather than business management. 


Want to learn more?

Be sure to attend conference sessions or workshops geared toward helping BCBAs navigate this new frontier. Visit some of the vendors that bill insurance at local and national conferences. These are the experts in handling insurance claims and have had much experience in the field. Also, remain connected with our professional organizations, such as the BACB, ABAI, and APBA, as they provide information on continuing education and legislation changes (some free of charge).
Final recommendations from professionals in the medical billing field suggest that professionals consider eliciting the services of a local health care attorney, as even the most experienced medical biller must receive continuing education and legal consult on the ever changing laws of the healthcare system.



Remember, the integrity of our field relies on ethical practice.

ABAI http://www.abainternational.org
APBA http://www.abainternational.org
BACB http://www.bacb.com/index.php?page=100259


References:
McCarty, J. (2006). Billing policies: What’s legal, what’s not. The ASHA Leader
Medicaid Fee Schedule. (2013). Retrieved May 30, 2013 from http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo/index.html?redirect=/feeschedulegeninfo/
The U.S. Department of Health and Human Services. (2013) Annual Poverty Guidelines. Retrieved May 30, 2013 from http://aspe.hhs.gov/poverty/index.cfm



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