HMO Billing Headaches!!

Health Maintenance Organizations commonly known as HMO's and now called MCO's (Managed Care Organizations) all have different ways in which their claims are submitted. My experience has shown that customer service within these organizations will not give out any useful information on how or why claims are being denied except for the deny codes that are sent alongside the processed claims. From my experience, Aetna insurance has one of the easiest platforms for Home Health claims processing. They do not pay as much as UHC and Amerigroup but you get paid ON TIME! Within the past year, UHC claims department is known to have loads of issues. Many home health agencies refuse to take up Therapy services under United Health Care. 8 out of 10 claims are either denied or under paid!

The purpose of these post is to get input from professional billers in the industry to know what they are doing right to get their claims processed promptly and paid as per contracted rates. I recently tried billing Amerigroup Skilled Services (G0154, G0151) and my claims were denied. A colleague told me I should use code 321 as TOB (Type of Bill). I'm waiting to see if these claims will be paid according to contract. My worst experience has been with Humana! I have billed those claims like 7 times and all denied, finally given up and accepted my losses. In the past Carecentrix used to be one of the best HMO's to work with, this is not the case now. We do not take up any client that is with Cigna or Carecentrix anymore, my experience has also been horrible with them.

Here are some tips I would like to share with my colleagues in the industry, your comments will be very helpful:

• If you receive a referral from another agency, carry out due diligence on the patients HMO. 7 out of 10 times the other agency is either not getting paid or being under paid for services rendered
• If you get a call from an HMO asking if you would take up a patient, do not be quick to take up that patient. It's either the patient lives very far away or other agencies have refused to take up the client because they do not pay!
• For traditional Medicare clients, PLEASE ensure that you meet up with the FACE TO FACE guidelines and PHYSICIAN SIGNATURE requirements. If you are among the unlucky ones to go through an ADR (Additional Documentation Request) all the monies paid to you on the clients under review will be recouped if the above are not met!
• Make sure your POC (Plan of Care/485) is properly signed by the physician before you bill for a Medicare client. It is considered fraud by CMS if they walk in to your agency and ask for documentation in this regard

I was watching the news the other day and it was stated that a home health agency defrauded Medicare and Medicaid of over 18 million dollars in false claims. I'm sure some of us here that a lot. Trust me some of the agencies labelled in this manner did not technically defraud the government, they just did not have documentations that met the required guidelines!

Please share your experience on various billing issues and events so that some of us can learn from you. Have a productive day at work :)

PS: Any news on how the HMO's plan to revert to EVV???

HOME HEALTH LEADERSHIP TRAINING TIPS (2)

THE IMPORTANCE AND ART OF EFFECTIVE NETWORKING

Networks are loose associations of two or more individuals who share common interests and objectives. Networking is an important element for success in the Home Health industry

Benefits of Effective Networks:

• Allows for the free flow of information which ensures that an individual is well informed about changes and opportunities in his/ her field of interest
• Provides access to tangible tools, skills, and referrals
• Provides positive personal and professional supports
• Leads to more established relationships such as partnerships

 

TIPS FOR EFFECTIVE NETWORKING

1. Follow-up and follow-through is critical
2. The most effective and sustainable networks are ones in which the individuals have established some level of trust and respect based on a successful interaction in the past
3. Popularity does not necessary translate into effective networks
4. Maintain your network
5. Check in periodically with the people in your network.
6. Make regular phone calls
7. Plan outings to discuss issues of common interest to both parties i.e. lunch
8. Correspond on a regular basis through emails, text messages or letters
9. Send greeting cards to celebrate special occasions and to provide support during times of loss
10. Buy lunch ;)

 

 Cowardice asks the question – is it safe?

Expediency asks the question – is it politic?

Vanity asks the question-is it popular?

But conscience asks the question- is it right?

And there comes a time when one must take a position

that is neither safe, nor politic, nor popular; one must take it BECAUSE it is right.

Dr. Martin Luther King Jr.

Social media has created a great platform for people to interact and share information. Many of us do not harness the opportunities that has been created for us to expand our reach and garner relevant information. We have social sites like LinkedIn, Facebook, etc.. One that has really worked for me is Craigslist. I remember in 2012, I got my first gig by posting services on Craigslist. It was surprising because I did not expect the kind of response I got. I've also leveraged on colleagues in my industry to either get more information or create value for them. The best opportunities in most cases are spun out of effective networks.

There's a saying that when you meet someone "relevant" for the first time, you need to make contact with that person within 24hours. Imagine you are fortunate to meet the CEO of a company you have always been interested in at a seminar. You exchange cards and part ways. It's always good to at least send an email reminding him of who you are and where you met when it's still fresh in his memory. This worked for me early in my career. I met someone who ordinarily would be difficult to approach under normal circumstances, this was at a training event. We were made to use adjectives that described our personalities with our names. For instance my name is Tolu so I called myself Timid Tolu (lol). That was the first adjective that came to my mind when I was asked to give my name. This exercise made it easier for everyone to remember eachother's names in the group. This really worked. After the 5 day training program, I called this gentle man on his cellphone (we all were made to exchange contact information) and he asked "who is this" and I said "this is Timid Tolu, am I speaking to Tall Taju" and he busted out laughing :) This connection is still one of the best I've had in years!

The focus in building effective networks is placing yourself in areas that are relevant to your growth and development not just meeting people for the fun of it!

Success = Opportunity + Preparation