Author Topic: Need Crash Course in What Non-Par with a Medicare Advantage Plan Means for LCSW  (Read 2162 times)

TMCGEATH

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Hello All!

I ran into a situation that I have no experience with - I bill for a LCSW who is in network with Medicare. I called to verify benefits for a potential new client and was told my LCSW was non-participating which simply meant she would need to fill out an Initial Behavioral Health Outpatient Form and fax it back to them (WellCare) and that the patient still had her $15 copay just like she would be charged with a participating provider.

I typed in non-participating here on the boards and got a little overwhelmed. I read something about needing to charge the patient for everything up front because the patient will get the payment, not the provider? I also read something about there being no real set fees if you are non-par?

What am I missing or not understanding? It sure seems WAY to easy to think that I just bill normally and my LCSW just simply collects the $15 copay if she is non-par with a Medicare Advantage Plan!

Tracie McGeath
Precision Billing and Business Services

Christy

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it sounds like perhaps they are granting you an out of network authorization? each insurance company is very different in how they handle out of network.

give them a call back and ask them to explain the payment process....

rdmoore2003

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I am not understanding.  Is the LCSW networked or not?

PMRNC

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Christy is right, on some occasions an out of network provider will treat as IN network with special authorization. They do it on a case by case basis and it depends on the area of the provider, the type of provider, etc.
If the carrier is BCBS you will want to collect from the patient as they will only honor assignment of benefits from a participating provider. Otherwise you can use an AOB, have the patient pay their copay. Your authorization will actually spell this out. You will want to make sure you put in your authorization and record how many visits along with documetnation that they are authorizing at in network rate.  A lot of EAP work this way, MAKE sure this is NOT an EAP.. If it is an EAP you want to be DOUBLY careful of documentation and make sure NO visits get billed to the major medical or TPA!!   A lot of times bilers get these out of network authorizations and don't realize they are EAP sessions!
Linda Walker
Practice Managers Resource & Networking Community
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