Billing for Addiction Medicine...

[Minimole]

My business has focused entirely on billing for mental health and continues to grow entirely due to "word of mouth" referrals.

Recently one of our clients referred an internal medicine physician to us, who specializes in addiction and has a good size practice involving Naltrexone treatment.  If we pick up this account it would be much more intensive work than what we are doing now.  It could also open up a whole new area for us, but I'm scared to death of getting in over our heads.  This account would product more revenue than the LPC, LCSW, and PsyD accounts.  We are not coders...and I don't really want that responsibility anyway.  Does anyone have any input they can provide?  I have not yet met with this physician, so any "words of wisdom" would be appreciated. 

Thank you!

[Michele]

It is always scary to get into something new.  In my experience the fear is always over exaggerated.  Throughout the years we have been approached to do billing for a specialty that we haven't done before.  We are always honest in our meeting with the provider, however as our confidence grew we would say something like "we aren't currently billing for any addition medicine providers however we are confident in our billing experience."  I'm not trying to downplay the importance of understanding the specialty you are billing.  However, sometimes people get so tied up in the details that they miss the opportunity.  I would encourage you to read what you can on billing addiction medicine, and go into the appointment with confidence.  Your billing experience with mental health will get you farther than you know.  Reading eobs, filing appeals, working aging reports, is basically the same.  You will just have to learn the little differences for addiction medicine.  We bill an addiction specialist.  For the most part it is the same as regular office visits.  The billing should come to you already coded.  Good luck!

[Minimole]

Thanks for your response Michele.  I'm confident that we can handle the work.  My anxiety is stemming from the fact that this is currently a cash/check business and not accustomed to submitting claims through either government or private insurers.  I'm thinking the best way to go would be to contract with a coder to create a Superbill to work from.  As I said, we're not coders.  The area of coding is my greatest concern due to the fact I have found some practitioners are not as knowledgeable in this area as one might think.  Any additional thoughts regarding my coding concerns would be appreciated.

[Michele]

Are they switching from a cash business to insurance?  That's interesting.  I wouldn't have expected an addiction medicine provider to be cash, but I don't blame providers who want that kind of structure!

I would just make sure the provider understands that you are billers, but not coders.  But don't emphasize it so much that you scare them!  Having a superbill drawn up for them (if they don't already have one) is a good idea.  When I am in a meeting I say something like "We are billers, but we are not coders.  However we do know how coding can affect billing and if we see something that we don't think is right, or that we know will cause a denial we bring it to your attention to make sure you have coded it the way you intended.  We also make you aware if there is anything you are doing that looks incorrect.  We don't ever change coding on our end since we don't have access to the patient's charts and we are not certified coders." 

[Minimole]

Thanks, Michelle.  Yes, they are currently all cash.  What you advised is basically the direction I was taking, so it's nice to know that I'm on the right track with this.  They are unsure whether or not revenues will increase if they start accepting insurance.

I was going to suggest having a coder create a superbill for them and to stay non-par for a while.  They could continue to collect the full payment up front, we would submit claims based off of the superbill, and the patients would be reimbursed by the insurer, if applicable. Given the fact they are moving from a cash only system to accepting insurance, I just think that it might be better for them to operate as an out-of-network provider for a while -- rather than jumping in with both feet.  What are your thoughts about that?

[Michele]

That sounds like a reasonable suggestion.  I'm curious as to why they are going from cash to insurance.  Is the cash not working that great?  Most providers want to go from insurance to cash and not vice versa! 

The only issue with your suggestion is that out of network claims are usually processed completely differently than in network so submitting out of network may not give a good picture of what will happen if in network, but it would give you a picture of what services are allowed.

[Minimole]

Thanks!   

[PMRNC]

Can I throw something out there that might not be relevant to what your asking?

I too have good word of mouth reputation in a few states as I started my billing company with mental health.

They are really scrutinizing the hell out of internal medicine, family practitioners prescribing those meds (methadone, suboxone, etc) HIGHLY regulated industry and not just with regards to billing but other area such as OSHA. SOMETIMES these practices are refusing insurance to stay under the radar. I'm NOT assuming that's case here. It just leaves one scratching their head as to why patients would pay cash for a service their insuranced would most likely HAVE to pay (due to existing and now new mandatory treatment regs)   I have seen from a few angles how this works. Doctor gives out the meds to patient, patient earns their take home, patient sells take home, doctor gets a cut. Sometimes the reason they start doing this is as simple as a town or county ordinance that won't let them distribute or provide those drugs so they do it "cash" and again, stay under the radar.

Again, I am NOT saying this is the case. I am the ultimate pessimist because not only have I seen doctors busted for this but I have known people (patients) do this with their doctors. It's actually bad rampant in some parts of NJ and NY. Since they don't take insurance they fly under radar and using the status of their practice (family, internal med) etc. Often kickbacks are also involved.

My intentions are good I promise. You can disregard, but if it were me I'd have to do a little more research before I took on this type of practice. Proceed with caution.