Medical Billing Forum

General Category => General Questions => Topic started by: Angie on October 04, 2011, 01:07:15 PM

Title: Billing Services
Post by: Angie on October 04, 2011, 01:07:15 PM
We only provide our families with a superbill when they request one to try to seek reimbursement from their insurance company because we do not participate with any of the insurance companies as they do not cover our type of facility. Sometimes when the client transfers to an aftercare program and it is denied the families will hire a company that specializes in denials which at that point that company will take all of their medical claims and try to help them. My question is it legal for that company to take our superbill and prepare it onto a UB04 or 1500 without our knowledge and submit it to the insurance company? And at times they will alter it and try to bill it under the facility instead of the provider we have on the superbill? I recently received a call from Blue Cross asking why we billed these services on a UB04 when they are for professional charges and why we billed it under the facility instead of the provider. I had told them that we did not do that and she proceeded to tell me also that someone is calling Blue Cross trying to get us set up as a out of network facility instead of out of network individual providers which we did not do. She gave me the name of the person that called so I know the company that is doing this and they are in no way affiliated with our company or contracted with us at all......Is this legal to do does anyone know???? Don't they have to have some kind of contract with us to do this????? She said it sounds like they are trying to represent our company.
Title: Re: Billing Services
Post by: Michele on October 05, 2011, 07:20:25 AM
Wow, haven't heard of that before!  I know when you have a facility that does not accept insurance that it is common for the patient to try to get reimbursement for services. 

As for if it is illegal, I don't know but it certainly sounds unethical!  Did you ask BCBS if there was anything you could do since this person was not affiliated with you?
Title: Re: Billing Services
Post by: Angie on October 05, 2011, 07:55:27 AM
I asked her if they could do that when they are not even affiliated with us and she said that it didn't seem like it and was very taken back by it but she was going to report it to the fraud and investigation dept to have it checked out. This company will also email me and ask me to forward all therapy notes along with the full medical chart like I am an employee of theirs without any kind of release from the parents. I don't do anything or even respond to them until I send the parents a release form but does she always have to have the personal therapy notes unless the insurance is requesting that directly? Do you know? She emailed me at one point and told me that it is the law that we provide the personal therapy notes when they are requested by anyone if there is a release on file. It just seems like it is a lot of personal information she is sending to the insurance when they are not going to cover our type of facility for one and she knows that and they are not requesting them, she is just sending them in with her claim she has prepared from our superbill when the parents have not even submitted it yet and received a denial or any type of payment.
We try to do everything we can to help the families seek some reimbursement as a courtesy because the insurance will not cover the facility itself so we don't accept insurance and we do not get into the whole appeals because the insurance simply will not cover our type of facility but they will reimburse their members for a portion of the therapy sessions that are provided directly by the therapist so it just seems REALLY unethical that she just takes the superbill that I provide to the parents as a courtesy for them to submit with a detail of how to submit it and then she just transfers it onto an actual claim form and charges the parents out the ying yang for it......just seems really shady!
Title: Re: Billing Services
Post by: Michele on October 06, 2011, 06:54:33 AM
It does sound very strange.  We have done work like this ourselves and we don't request the therapy notes.  Unless she is some kind of certified coder who is going thru the notes to bill for each service independently, I can't figure why she wants them.  Also, maybe to attach to the claim because she feels that it helps with getting reimbursement??  Not sure.  I would continue to do as you are:  No response without a signed release, send info if you have a release.  Unfortunately the way she goes about her business alienates people and makes them not want to cooperate with her.  I come from a completely different angle and usually the facilities are very cooperative.  I am strictly trying to help the patient get reimbursement for what they are entitled to and bill exactly what services were provided.

I'm curious how she gets paid??  Possibly a percentage of what she gets collected?? 
Title: Re: Billing Services
Post by: Angie on October 06, 2011, 07:50:04 AM
I am not sure how she gets paid for her "Services"! And you are right, she does go about it the wrong way. It is good to know that there are people out there like yourself and your business! Your books and this forum have been the most helpful to me. I have purchased so many books and attended a few webinars that really are of no use! Your books are so informative and so easy to read and understand and "who takes the time to provide a forum like this", I have never found anything like it! It is the best thing I have come across and I will continue to refer your services and books to everyone I know!
Thanks again Michele
Title: Re: Billing Services
Post by: Michele on October 06, 2011, 07:30:16 PM
Thank you for the kind words.  We vowed from the beginning to help others since we had such a hard time getting any help.  Many people only take time to say the negative.  We appreciate the positive as it reminds us why we do this.  (We also appreciate the negative because we try to use it to improve and better ourselves ~ but it stings!)

Title: Re: Billing Services
Post by: DMK on October 07, 2011, 10:35:02 AM
You may not always hear what you want to hear, and you may not always agree, but this site has been SO valuable for my self esteem by reinforcing what I DID know, correcting what I DID NOT know, and confirming or denying what I THOUGHT.

These ladies and gentlemen are SUCH A VALUABLE FONT OF KNOWLEDGE!
Title: Re: Billing Services
Post by: Michele on October 07, 2011, 05:57:41 PM
Even though we provide the forum, we learn from it as well.  It is a two way street and we appreciate all who take the time to share their knowledge and experience.
Title: Re: Billing Services
Post by: ascbiller on October 09, 2011, 02:36:41 PM
What type of facility is it that is not covered? What state are you in?
Title: Re: Billing Services
Post by: Angie on October 10, 2011, 07:22:19 AM
It is a Therapeutic Wilderness Program. We are not licensed as Residential Treatment or Inpatient.
Title: Re: Billing Services
Post by: Angie on October 10, 2011, 09:58:36 AM
So Michele when you prepare a claim for a patient do you check with that facility first before you prepare it or do you just prepare it off of what the patient provides to you. Say you receive a superbill from a patient, would you just take the information off of that and convert it onto an actual claim form? Or would you contact the facility first? Can a billing service just prepare a claim form for a facility without the facility knowing they are doing so???
Title: Re: Billing Services
Post by: Michele on October 10, 2011, 11:43:46 AM
We almost always contact the facility first.  The only time we don't is when the patient provides us with info and absolutely everything needed is present.  ALso, the patient will state that the facility provided them the info so that they could submit their own claim.  Many times the facility just doesn't know how to complete the UB04.  We NEVER contact the insurance carrier.  We are strictly working for the patient to put the information into the required format.  We also include all information received from the facility so that the insurance carrier can see that our codes match what the facility provided.  We are not trying to code so that the patient gets reimbursement, we are strictly transferring the data.  We have talked with many facilities who are usually very cooperative and grateful that we are helping the patient since they can't.  Also, we have had facilities refer people to us. 
Title: Re: Billing Services
Post by: Angie on October 10, 2011, 12:08:24 PM
Thanks Michele. I will be referring clients to you if we run into any problems! I was just wondering if one could just prepare a claim with just an invoice that says "Prepaid days" and amount or "Extended days" and amounts for the wilderness program. It has no codes on it other than a diagnosis code that they received from records they received. They just put a code on the UB04 as :type of bill: 0132 which is hospital, outpatient and we are not a hospital we are a wilderness program and for the rev code they are using 0169 which we did not provide. Also this company is preparing 1500 forms from information that we provided to the parents and are signing them without our knowledge. I just didn't know if this was standard practice for a billing service to do so.
Title: Re: Billing Services
Post by: Michele on October 10, 2011, 06:36:00 PM
The UB04 does not require a signature.  The CMS does (or at least the indicator that you have a signature on file!).  I would not use 0132 for the type of bill for a wilderness program.  There are appropriate type of bill codes that could be used.  Sorry you have had to deal with an unpleasant situation.  :(
Title: Re: Billing Services
Post by: Angie on October 11, 2011, 07:46:25 AM
Thank you again for all of your help.
Do you know if the 0169 rev code "Other General Classification" under "Other Room and Board would be an appropriate rev code for the full wilderness program?

I think that the type of bill would be 0842 which is Special Facility, Other, 1st claim..... if we did have to provide a UB04 claim for the program. Do you agree that would be appropriate????
And if we had to provide a claim for just the therapy sessions 0832 which is Special Facility, Outpatient, 1st claim?

Do you think you could whip out a book on "wilderness program billing"! ;)
Thanks so much for all of your help with this, very much appreciated!
Title: Re: Billing Services
Post by: Michele on October 13, 2011, 06:43:19 AM
Type of bill 0842 probably would be fine, because as we've been stating all along, it probably won't be reimbursed.  I wouldn't change it to outpatient even when billing the therapy sessions.  The patient was inpatient when the sessions took place.  As for the rev code for room and board, I would use the regular room & board rev codes, whether is is private, semi-private etc.  The room & board is room & board.  The type of bill indicates where the room & board is, and the facility name as well. 

As for the book, I'd have to put it in line......we have so many projects we are trying to get to!

Title: Re: Billing Services
Post by: PMRNC on October 25, 2011, 09:00:34 AM
My question is it legal for that company to take our superbill and prepare it onto a UB04 or 1500 without our knowledge and submit it to the insurance company?

No, it's not illegal at all. In fact many Union's and other self-funded policies still require the patient to submit the claim form. My plan up until just last year gave me forms to complete and submit. Also there are still companies providing CAP services for patient's and they need only obtain the proper forms for patient consent.. as for record's your only obligated to release them to the patient and I wouldn't do anything for anyone but the patient and then let them go from there (self-disclosure)  My dental plan still requires me to send in the stupid handwritten form so I give it to my dentist. Many self-funded plans have not caught up to the times due to cost restraints. 

Another thing I'm wondering is that could it be an A/R Factoring company?  I had a provider one time go out to dinner with some guy and next thing I know the guy is contacting me for the AR because the doctor signed the A/R over.. without even looking into all the ramifications and consequences.. I bowed out of that client fast because he was planning on retirement and I knew this was going to cause a lot of headaches when patient's called about bills they knew nothing about!  He didn't even tell me until AFTER the fact and expected me to just turn over the A/R!
Title: Re: Billing Services
Post by: Angie on October 25, 2011, 11:51:57 AM
Linda has your company ever done any billing for a therapeutic wilderness program or I should say have you had an experience with it? If so I would LOVE some advise!
And I agree with a comment on another topic posted today; with you and Michele's combine 50 years experience! This forum has been a breath of fresh air and I am so grateful for all of your knowledge you ladies are willing share! Just to put that out there   ;)
Title: Re: Billing Services
Post by: PMRNC on October 25, 2011, 12:21:01 PM
Linda has your company ever done any billing for a therapeutic wilderness program or I should say have you had an experience with it? If so I would LOVE some advise!

No actually I am a bit flushed to ask..but what kind of therapy is that? I had a provider who specialized in pet therapy and that was different but very straight forward since the carriers did not cover it. 

Title: Re: Billing Services
Post by: Angie on October 25, 2011, 12:46:15 PM
Sorry I was not more clear.....
The students (ages 12-17) live in the wilderness for 6-8 weeks with the field staff (who are not licensed therapists) and our licensed therapist (LCSW, Psychologist, Ph.D., ect) go to the field 2 days a week and provide individual (face to face) therapy sessions and group therapy sessions, hand out therapeutic assignments for the week ectů also they do a family therapy session over the phone weekly . It is kind of like Residential Treatment but in the wilderness (without four walls). The diagnosis of the students are typically dealing with Major Depression, Oppositional Defiance, ADHD, PTSD ect..more of a mental health diagnosis. Typically after our program they go to Residential Treatment for a more long term care.
I hope that helps....
Title: Re: Billing Services
Post by: PMRNC on October 25, 2011, 03:29:37 PM
Thank you for the clarification, and no I really have not dealt with those circumstances at all. I have clients of course that treat patient's for those conditions, but not in the "wilderness" type setting. I'm sorry :(  Do the insurance carriers cover it? if not are they denying it because of "place" of service or provider type?
Title: Re: Billing Services
Post by: Angie on October 25, 2011, 03:56:37 PM
I have yet to find an insurance that will cover the program. Most of the insurance companies will reimburse their members for the face to face therapy sessions with the licensed therapist. If they request we will provide them with an itemized statement of those sessions for the families to submit for reimbursement. I just have student's families asking all the time if we can prepare a claim so they can submit to their insurance for the program and there is no rev code for "Wilderness Program" and we are not licensed as residential treatment so we cannot put that either......I know of another billing company that says that they bill for the full program and then if it gets denied they appeal it (don't know how but that's a whole other issue) They have actually taken an invoice from one of our families that have hired them and they have prepared a UB04 and submitted it to the insurance which makes me nervous because we will not bill the insurance directly and on the type of bill they are putting it as 0863 which is residential treatment......I also see alot of itemized statements from other wilderness programs and it looks as though they are just doing a running invoice and coding a group session everyday, when i know for a fact that the therapist did not provide the group directly because they are not in the field 7 days a week..... and I am not sure how that works.....I have families asking why we cannot do that but I wont do anything without the therapist notes; correct.......You cannot prepare an itemized statement or superbill without the proper notes from the licensed therapist is that how you view it? Just looking for someone else's view from this......
Title: Re: Billing Services
Post by: PMRNC on October 25, 2011, 04:21:13 PM
Well, again, it's not a rule that a patient or even someone on behalf of a patient sending in a claim form, but I too would be leary if there is any false information being sent in. A good idea might be to be sure your office is completing them and then in your office policy make it something they are aware of that they should NOT be filing anything aside from the superbill/invoice.  By law all heatlhcare providers are obligated to provide the exact billing information they would to an insurance company to the patient upon request, be it on a superbill or invoice or the Billing form, which is why I think it would be a good idea for you guys to have prepared to avoid any of this problems. As for the coding, I really can't help with that as I don't do UB04 billing at all. I've never billed therapy in that setting before but just from your description it sounds like insurance carriers have a hard time with the "setting" and the license of the provider?  or is it because you don't have a "facility" per se TO license as a residential treatment center?
Title: Re: Billing Services
Post by: Angie on October 25, 2011, 04:39:23 PM
It is the licensing, "Wilderness Program". They don't have a problem with the LCSW or psychologist but the "setting".....Some insurance companies look at the sessions as an outpatient service 90806, 90853 ect..even though they are being provided within the wilderness program, they reimburse their members that way but there are some that will not even reimburse for the sessions because they are being provided within the program.....I know how to prepare a UB claim form, I am just unclear on the coding.....(since we are not inpatient, or outpatient.....) I don't know what to put for the type of service so it is not misleading to the insurance and nobody has an answer. (I am an overworrier!) And I am unclear how the other programs are providing a superbill with a group session 90853 on there everyday when the licensed therapist is not providing the service...... We have parents asking us to do this all of the time but it is my understanding that we cannot unless we have a therapy note with the therapist signature, is that correct?
I really appreciate all your input!