The Rescue Biller™

1 Overview of Modules 2 One Lesson Spotlight 3 Sitemap

1 Appeals 2 Appeals to Medicare Advantage plans 3 Claim Denials - due to medical necessity 4 Claim Denials - not due to medical necessity 5 Clawbacks: basic info 6 ERISA 7 Go directly to the top: Writing to CEO’s 8 Grievances 9 "Medical Necessity" & Clinical Practice Guidelines 10 Medicare: Redetermination 11 Retroactive benefit determination clawback 12 Retroactive coordination of benefits clawback 13 What to do when you first receive a denial

1 Audit tools 2 Audits when you're out of network! 3 Documentation Audits 4 Medical Necessity Audits 5 Medicare Supplemental Medical Review Contractor 6 Medicare Target, Probe & Educate 7 Pre-payment reviews 8 Recovery Audit Contractor 9 Risk Adjustment 10 Special Investigation Unit audits 11 What causes audits? Is there anything I can do to avoid being audited? 12 When the audit letter arrives, what do I do?

1 BCBSA: The National BCBS Association 2 BCBS licensees/states 3 Blue Card 4 Blue Cross vs Blue Shield: Is there a Difference? 5 Cross-border contracting 6 FEP: Federal Employee Plan 7 Home Plan 8 Local Plan - where to submit claims! 9 Medicare Primary Exception to Blue Card Procedure 10 Multiple-Blue States: California 11 Multiple-Blue States: Idaho 12 Multiple-Blue States: Kansas 13 Multiple-Blue States: Missouri 14 Multiple-Blue States: New York 15 Multiple-Blue States: Pennsylvania 16 Multiple-Blue States: Virginia 17 Multiple-Blue States: Washington 18 Out of network with BCBS? CAUTION! 19 Prefix 20 Telehealth billing & BCBS 21 Your patient portal & BCBS

1 Choosing the right business structure (Sole Proprietor, LLC, PLLC, etc) 2 Group Practice: Should I join a group? 3 Group Practice: Starting a Group as an Owner or Co-Owner 4 Group Practice: The national telehealth mega-groups 5 Hire a biller? What will work best for me? 6 How do I choose the best EMR / billing software? 7 I'm at the very beginning. What things need to be done first, second, third, etc? 8 Leaving a group to start your own practice 9 Marketing your practice 10 Non-insurance services 11 Non-clinical practice policies / forms 12 No-Show Fees 13 Psychology Today and other internet listings 14 Setting your fees 15 Should I hire associate licensees? 16 Tax ID vs Social Security # ? 17 Your practice's website: tips

1 Add-on codes 2 Behavioral Health Integration 3 Brief emotional/behavioral assessment (96127) 4 Collaborative Care Management 5 CPT 6 Crisis Psychotherapy 7 Diagnosis codes that can't be primary 8 Diagnosis coding / ICD-10 9 Evaluation & Management (prescribers only) 10 Extended sessions 11 HCPCS / Healthcare Common Procedure Coding System 12 Health & Behavior Assessment & Intervention Codes (HBAI) 13 Hospice-enrolled modifiers (GV, GW) 14 Interactive Complexity 15 Modifiers 16 Place of Service Codes 17 Psych & Neuropsych testing 18 Psychotherapy Codes

1 Balance-billing (in-network) 2 Can a client with insurance choose to self pay? 3 Can I offer sliding scales (when in network)? 4 Care Credit 5 Credit cards: mandating a card on file 6 Credit cards: surcharges & convenience fees 7 Deductible 8 No-show / late cancellation fees 9 Preventing balance build-up 10 Refunds vs. credit toward future visits 11 Should I use a collection agency? 12 Talking to clients about money 13 Waiving deductibles/copays: why is it not ok? 14 When the client disputes what they owe 15 When the client has two insurance plans 16 Writing off balances

1 Anti-Kickback Statute 2 Compliance Plan 3 Corporate Integrity Agreement 4 Exclusion 5 Fair Debt Collection Practice Act 6 False Claims Act 7 FDR (First Tier, Downstream, & Related Entities) 8 Fraud, Waste, Abuse (annual training for Medicare Advantage) 9 In everyday language: What's insurance fraud? 10 Mental Health Parity & Addiction Equity Act (MHPAEA) 11 Model of Care Special Needs Plan training (annual training for Medicare Advantage) 12 No Surprises Act 13 OIG Self-Disclosure 14 PCI Compliance (credit card security) 15 Stark Law 16 Who or what is the OIG?

1 Accepting new clients status 2 Availity 3 CAQH: Attesting 4 CAQH: Updates 5 Changing Address 6 Changing NPI & Accessing NPPES 7 Changing Tax ID 8 Keeping private practice separate from another group/employer 9 Moving to another state 10 Provider Directories: attestation, maintenance & suppression 11 Recredentialing 12 Revalidation 13 The W9 form

1 Billing an EAP 2 Clinical considerations: short-term, assess/refer, dual-client 3 Evaluating an EAP contract 4 How EAP is different from insurance 5 Non-counseling EAP services 6 Pros and Cons of joining an EAP panel 7 What's a CEAP and do I need one?

1 Availity, payer portals 2 Clearinghouse 3 Do I have to bill electronically? 4 EDI Enrollments 5 EDI transaction types 6 Electronic Medical Records (EMR) system 7 ERA: Electronic Remittance Advice 8 EFT / Other Electronic Payment Methods 9 Payer ID / Payer List 10 Practice Management (PM) System 11 Submitter ID 12 Trading Partner

1 Accounting of Disclosures 2 Breach / Breach Notification 3 Business Associates 4 Covered entity 5 Developing your HIPAA compliance plan 6 HITECH Act 7 Minimum Necessary 8 Notice of Privacy Practices 9 PHI / Protected Health Information 10 Privacy Rule 11 "Psychotherapy Notes" - as defined by HIPAA 12 Scalability 13 Security Rule 14 Substance Use Disorder records regulations 15 Transactions/Code Sets AKA "Administrative Simplification" 16 Treatment, Payment, Operations (TPO)

1 ACA / Affordable Care Act 2 Balance-Billing 3 COBRA 4 Coinsurance, Copayment...is there a difference? 5 Contracted Reimbursement Rate 6 Coordination of Benefits (CoB) 7 Crime Victims Compensation 8 Deductible 9 Directory 10 Employer/Group Health plans: Self vs Fully Insured 11 Essential Health Benefits 12 Explanation of Benefits (EOB) / Remittance Advice (paper or electronic) 13 Grace Period 14 HSA, HRA, FSA ... understanding the alphabet soup 15 Health Sharing Arrangements 16 ICN / DCN (aka "Claim Number") 17 Individual Mandate Penalty (ACA) 18 Insurance Cards - Decrypting their Secrets! 19 Insurance Plan Design (HMO, PPO, etc) 20 Insurance plan funding types 21 Mental Health Carve-Out 22 Narrow Networks 23 Payer Coverage Policy vs Covered Benefit 24 Pended Claim 25 Prompt-Payment laws 26 Provider Network 27 Qualifying Life Event 28 Rental networks & Silent PPO's 29 Repricing 30 Short-term catastrophic health plans 31 State Insurance Commissioner 32 Superbill 33 Third-Party Administrator (TPA)

1 Agreeing to be rented out? 2 Assignment / Accept Assignment / Assignment of Benefits 3 After-hours coverage 4 Appointment Access 5 Can I negotiate anything? 6 Collecting patient responsibility amounts 7 Independent Contractor 8 No balance-billing 9 Non-discrimination (It's not what you THINK it means!) 10 Plan Bankruptcy - hold client harmless 11 Provider manual 12 Terminating your contract 13 Timely claims filing

1 CAQH 2 CAQH ProView 3 Contracting 4 Credentialing 5 Delegated Credentialing 6 Disclosure questions 7 "Full" panels - what can you do? 8 National Practitioner Data Bank 9 National Provider ID / NPI 10 Negotiating a Rate Increase 11 Primary Source Verification 12 Roster 13 Single Case Agreement

1 Clinical Documentation 2 Liability Insurance PPO Networks 3 Prior authorization - working with the nurse case manager 4 State Fee Schedules 5 State Work Comp Departments 6 Subrogation 7 What is Jopari? 8 When the client also has Medicare

1 Aetna Better Health 2 Anthem-owned Medicaid Managed Care (Wellpoint, Amerigroup) 3 Can I collect cash from a Medicaid client if I don't accept Medicaid? 4 Centene Medicaid 5 CHIP 6 Healthy Blue 7 How Medicaid pays when secondary to Medicare 8 Medicaid expansion under the ACA 9 Medicaid Managed Care 10 Molina Medicaid 11 Recognizing a Medicaid client 12 United Healthcare Community Plan 13 What is Medicaid?

1 Advanced Beneficiary Notification (ABN) form 2 Benefits Coordination & Recovery Center (BCRC) 3 Contacting Medicare 4 Dual Eligibles (people with both Medicare and Medicaid) 5 Eligibility Inquiries 6 Medicare Administrative Contractor (MAC) 7 Medicare "Advantage" 8 Medicare “Advantage” vs Original Medicare 9 Medicare Beneficiary Identifier (MBI) 10 Medicare "Crossover" 11 Medicare Regional Offices 12 Medicare Reimbursement Rates 13 Medicare Secondary Payer (MSP) 14 Medicare Supplement (Medigap) plan 15 MIPS / Merit-Based Incentive Payment System 16 “Non-participating” provider status 17 Opting Out 18 Overpayments 19 PACE (Program of All-Inclusive Care for the Elderly) 20 Physician Fee Schedule 21 Preclusion 22 Provider Enrollment 23 Provider Enrollment: Accessing PECOS 24 Provider Enrollment: Appealing Enrollment Determinations 25 Provider Enrollment: Deactivation 26 Provider Enrollment: "Development" 27 Provider Enrollment: Do Not Forward 28 Provider Enrollment: Enrollment forms (Which ones do I need?) 29 Provider Enrollment: Order & Certify 30 Provider Enrollment: Participating vs Non-participating 31 Provider Enrollment: Psychologists 32 Provider Enrollment: Reactivation 33 Provider Enrollment: Reassignment 34 Provider Enrollment: Revalidation 35 Provider Enrollment: Site Visit 36 Provider Enrollment: Using a Billing Service 37 PTAN (Medicare provider number) 38 Qualified Medicare Beneficiary (QMB) 39 Railroad Medicare 40 Redetermination (AKA Appeal) 41 Reopening = How to correct a Medicare claim 42 Reopening vs Redetermination 43 Sequester 44 Telehealth with Medicare 45 Tips: Dealing with the MACs 46 What are the Medicare benefits for mental health? 47 What mental health services are covered by Medicare?

1 1500 form 2 Access & Density Standards 3 ACO (Accountable Care Organization) 4 Accumulations 5 Advanced EOB 6 "Any Willing Provider" 7 Assignment / Accept Assignment / Assignment of Benefits 8 Bundling 9 Capitation 10 "Clean" Claim 11 COBA 12 Conversion Factor 13 Crossover 14 CVO (Credentials Verification Organization) 15 Gag Clause 16 Ghost Network / Phantom Network 17 Good Faith Estimate (GFE) 18 Health Professional Shortage Area (HPSA) 19 HEDIS 20 Interoperability 21 Limiting Charge 22 Medical Loss Ratio (MLR) 23 NCCI: National Correct Coding Initiative 24 NCQA 25 Network Adequacy 26 NUCC (National Uniform Claim Committee) 27 Payer of Last Resort 28 Pre-determination of benefits 29 Relative Value Units / RVU 30 Risk Adjustment 31 Secret Shopper 32 Subrogation 33 Summary Plan Description 34 Taxonomy Code 35 Upcoding / Downcoding 36 UPIN 37 Utilization Review / Utilization Management (UM)

1 ChampVA 2 Tricare 3 Tricare for Life 4 TRICARE: Joining as Participating vs. Certified/Nonparticipating 5 Tricare Procedure Pricing Lookup 6 US Family Health Plan 7 VA Community Care

1 Anti-Assignment: When a plan won't directly pay an out of network provider 2 Balance-Billing (out of network) 3 Client care when leaving the network 4 Courtesy Billing: Yes or No? 5 Payers attempting to force discounts! 6 Resources for clients 7 Sliding scales when out of network 8 Superbill

1 60-day rule 2 I owe a client. Is it ok to credit the overpayment to future visits? 3 Legal consequences of failing to refund 4 Refund an insurance payer by check? Or let them take from a future claim? 5 Unsolicited refunds to insurance payers 6 What do I do if the insurance won't take an overpayment back?

1 Aetna 2 Anthem/Elevance 3 Carelon 4 Centene 5 Cigna/Evernorth 6 Crime Victims Compensation 7 Humana 8 Kaiser Permanente 9 Magellan 10 Molina 11 United Healthcare/Optum 12 ***CEO & Executive contacts!***

1 Collaborative Case Management (CoCM) 2 Group Therapy 3 Behavioral Health Integration 4 Health & Behavior Integration codes 5 Psych and Neuropsych testing 6 Psychiatry / nurse practitioner - special issues with respect to medication 7 Seeing clients in assisted living and nursing facilities 8 Supervisory billing vs. Incident-to

1 1500 claim form 2 1500 form: Completing boxes 1-3 3 1500 form: Completing boxes 4-7 4 1500 form: Completing boxes 8-11 5 1500 form: Completing boxes 12-13 6 1500 form: Completing boxes 14-20 7 1500 form: Completing boxes 21-23 (Claim Correction!) 8 1500 form: Completing box 24 9 1500 form: Completing boxes 25-33 10 ANSI - loops and segments and ... WTF?! 11 Claim Adjustment Reason Code (CARC) 12 Claim Status Codes 13 Filing Indicator 14 Group Codes 15 How to read an Explanation of Benefits 16 Matching electronic remittances with direct deposits 17 Modifiers 18 NPI: Which one goes where?! 19 Place of Service Codes 20 Posting Payments, Deductibles & Denials 21 Rejections 22 Remittance Advice Remark Code (RARC) 23 Revenue Cycle Management (RCM) 24 Secondary claims submission

1 Coding & billing for telehealth 2 Distant Site 3 Documenting Telehealth Visits 4 Originating Site 5 Place of Service 02 vs 10 - which do I choose? 6 Resources

1 Accumulations 2 Determining what the client will owe 3 Eligibility Service Type Codes 4 Eligibility vs VoB 5 Interpreting insurance cards 6 Standard VoB Disclaimer! 7 When the plan doesn't pay as quoted 8 Whose responsibility is Verification of Benefits?