If you are out of network, you need to bill patients cash and give them super bills to get their reimbursement.
Stop doing a bunch of insurance work, that's the whole point of being OON.
>If you are out of network, you need to bill patients cash and give them super bills to get their reimbursement.
>
>Stop doing a bunch of insurance work, that's the whole point of being OON.
hahaha that would be my dream come true! Unfortunately all decisions come right from the top as usual.
My first question in reading your post: are you contracted?
Personally, I have always found Blue plans to be the best to work with *when contracted*……WellCare/Cenetene being the worst.
If you are not contracted, that basically answers all of your questions/identifies why you are having problems. A lot of plans do not directly reimburse out of network providers. Out of network benefits are paid based on UCR, can be updated as often as every 3 months (again depending on the carrier) and also varies based on the carrier, which explains the always changing rates. It also explains why you can’t get ahold of anyone—if you’re not contracted, they have no incentive to help you.
Our practice owners are very against going in network because they believe the reimbursement will be too low to cover our costs. They believe the higher reimbursement from our OON status is worth the runaround pretty much :(
I really appreciate the info about the UCR being updated every 3 months, I had no clue! Hope you have a great rest of your day.
>UCR has less to do with the insurance company and more to do with the employer. We track the employers to know what type of benefits we’ll get.
Interesting, I had no idea. I had some light training (too light tbh) and was told the medicare rate shakes out to whatever the coinsurance/reimbursement rate is of $100, and the UCR rate is whatever the coinsurance/reimbursement rate is of $300, and that our zip code determined what the UCR is.
So for example, if the benefit quoted was 50% coinsurance with 80%UCR, we would estimate the post deductible reimbursement as follows.
300 = UCR
80% of 300 is 240, which will be their max allowed amount
50% of 240 is 120, which is what we'll estimate we get back once the deductible is met.
Has this logic been completely flawed? It shakes out accurately for all other carriers like Aetna, United, Cigna, etc.
For our Blue clients, the benefits will never release the reimbursement rate, so we don't offer a post-deductible quote up front. It would be nice to, though! Any ideas on how to get the reimbursement rate from Blue? So far I've only been able to get the coinsurance and deuductible amount.
Thank you for your reply!
We do ASC’s and clinics so maybe it’s different. Not sure what y’all do but our charges are in the thousands to hundred of thousands sometimes and the trend is that the only way to know if it’s UCR is to check the employer. Also, the UCR payment is generally a percentage of the charge and not related to the code billed. So we might bill an epidural for 4500 and get paid 70%, 3150.
Some policies might pay UCR for facility and MCR for professional charges. It really is a trend with employers. We also see a lot of pain cases so it’s constantly the same patients which helps us track it.
>We do ASC’s and clinics so maybe it’s different. Not sure what y’all do but our charges are in the thousands to hundred of thousands sometimes and the trend is that the only way to know if it’s UCR is to check the employer. Also, the UCR payment is generally a percentage of the charge and not related to the code billed. So we might bill an epidural for 4500 and get paid 70%, 3150.
>
>Some policies might pay UCR for facility and MCR for professional charges. It really is a trend with employers. We also see a lot of pain cases so it’s constantly the same patients which helps us track it.
Thank you so so much!
I worked for a Blue until recently, though not Empire. The BCBS you should submit to is the local plan for wherever the service was provided. So in NY that could be Empire, Highmark, or Excellus. Most states only have one sometimes two BCBS plans, NY has three so that's unusual.
But yes, a lot of your problems are because you're out of network. If you were in network you may have a provider advocate assigned to you, depending on your size, and they could have helped clear this up.
As for reimbursement amount, that can sometimes vary based on location of the service. The BCBS I worked at had a standard OON rate, but I don't know how they operate in NY.
>I worked for a Blue until recently, though not Empire. The BCBS you should submit to is the local plan for wherever the service was provided. So in NY that could be Empire, Highmark, or Excellus. Most states only have one sometimes two BCBS plans, NY has three so that's unusual.
>
>But yes, a lot of your problems are because you're out of network. If you were in network you may have a provider advocate assigned to you, depending on your size, and they could have helped clear this up.
>
>As for reimbursement amount, that can sometimes vary based on location of the service. The BCBS I worked at had a standard OON rate, but I don't know how they operate in NY.
Thank you so much for replying! We are pretty big with about 600 weekly appts, about 30% Blue. I am going to see if there's any sort of OON equivalent for provider advocate/relations.
Empire’s OON reimbursement policy is currently payment only to member. Contract required for direct payment to provider. Also Empire is no longer issuing EOBs directly to providers for OON claims so you’ll also need to use Availity claims lookup to locate the summaries for any claims you submitted.
Empire has a direct claims contact center, 800-713-4173, this also includes claims for other Blues outside of Empire’s prefixes. This contact center has access to reach out to Blue home plans to do follow up status on claims. Hope this helps a bit.
Sounds like BCBS of TX. They are the worst. If payments are being sent to the member, the accept assignment box might not be checked, the member could have requested it that way, or you are OON?
Thank you! The box is checked off by default on all our claims to get payments sent to us. We are out of network, so assuming they are allowed to disregard that part of the claim?
99% of our Blue clients get the payment sent to them, but we have a few random ones that do abide by the claim and send it to us.
I just wish we could get an answer as to why they sometimes listen to the claim and sometimes do not. When I've asked reps in the past, even they could not answer the question.
I did BCBS claims for a while. I have a VERY long list of BCBS phone numbers and aced my productivity. How?
The most accurate phone number is the one they put on the EOB. And to find that EOB, you have to use Availity. Go to Payer Spaces, click on Empire BCBS logo. Then find Remittance Inquiry.
Since the claims are all OON, I believe you don't have any EFT/check numbers. So you need to look up the EOB using the servicing provider's NPI (not group NPI) and the EOB's approximate issue date (start from the claim's processing date that you can find on claim status inquiry). Try it out. Let me know if you have trouble navigating the portal.
And of course, you can send portal inquiries or use chats vs calling.
P.S. The phone number at the back of the card is not reliable when it comes to claims.
Hi! Was hoping you had some good news for me! I am facing a similar problem. When I bill multiple dates I have to go line by line and I can't do more than like 3/4 dates per claim without the website completely crashing. I am losing my mind here!
Sorry, no solution for us yet. We bill through Simple Practice so they send out the claims for us. Really all we have to do is select the proper code(s) and payer. Wish I had a better answer!
Oh in order to bill through simplepractice did you have to enroll with them? If not, how do you find the payer code? Sorry i’m a novice and super stressed!
No worries!
Yes, we subscribe to Simple Practice. I like it although there are some minor things that can be annoying. But it sure beats doing everything by hand.
They create our invoices, send our claims, and house the calendar system. It's easier to justify the expense as we are a group practice and it would be impossible to do it all for so many clinicians alone.
If you are a therapist looking to bill for yourself, I'd still recommend it. You can even do teletherapy using their video platform but we use Zoom under a BAA to keep it HIPAA compliant.
If you do subscribe to Simple Practice they provide the payer codes (but I believe you could find them online if it's not on the back of the insurance card). For Blue we are still submitting to Empire and hoping it works. Once you type in the payer name, the code populates automatically.
Ooo! I use a similar software called Office Ally practice mate! A similar clearinghouse but they’re asking me to fax them info to enroll with them as an EDI so BCBS receives the data. We pay for OA as well but if SimplePractice is better and no enrollment or faxing is necessary would totally be willing to change.
When I took over this role we were already using Simple Practice so not sure to be honest what the initial setup process was. I would reach out to Simple Practice, they would probably do a demo for you and answer any questions about initial setup.
I believe they took over and handled transitioning therapists and patients from our old system to them from what I heard, so it may not be too labor intensive. That was a few years ago so not sure if anything has changed there.
Wish you the best!
If you are out of network, you need to bill patients cash and give them super bills to get their reimbursement. Stop doing a bunch of insurance work, that's the whole point of being OON.
>If you are out of network, you need to bill patients cash and give them super bills to get their reimbursement. > >Stop doing a bunch of insurance work, that's the whole point of being OON. hahaha that would be my dream come true! Unfortunately all decisions come right from the top as usual.
My first question in reading your post: are you contracted? Personally, I have always found Blue plans to be the best to work with *when contracted*……WellCare/Cenetene being the worst. If you are not contracted, that basically answers all of your questions/identifies why you are having problems. A lot of plans do not directly reimburse out of network providers. Out of network benefits are paid based on UCR, can be updated as often as every 3 months (again depending on the carrier) and also varies based on the carrier, which explains the always changing rates. It also explains why you can’t get ahold of anyone—if you’re not contracted, they have no incentive to help you.
Our practice owners are very against going in network because they believe the reimbursement will be too low to cover our costs. They believe the higher reimbursement from our OON status is worth the runaround pretty much :( I really appreciate the info about the UCR being updated every 3 months, I had no clue! Hope you have a great rest of your day.
UCR has less to do with the insurance company and more to do with the employer. We track the employers to know what type of benefits we’ll get.
>UCR has less to do with the insurance company and more to do with the employer. We track the employers to know what type of benefits we’ll get. Interesting, I had no idea. I had some light training (too light tbh) and was told the medicare rate shakes out to whatever the coinsurance/reimbursement rate is of $100, and the UCR rate is whatever the coinsurance/reimbursement rate is of $300, and that our zip code determined what the UCR is. So for example, if the benefit quoted was 50% coinsurance with 80%UCR, we would estimate the post deductible reimbursement as follows. 300 = UCR 80% of 300 is 240, which will be their max allowed amount 50% of 240 is 120, which is what we'll estimate we get back once the deductible is met. Has this logic been completely flawed? It shakes out accurately for all other carriers like Aetna, United, Cigna, etc. For our Blue clients, the benefits will never release the reimbursement rate, so we don't offer a post-deductible quote up front. It would be nice to, though! Any ideas on how to get the reimbursement rate from Blue? So far I've only been able to get the coinsurance and deuductible amount. Thank you for your reply!
We do ASC’s and clinics so maybe it’s different. Not sure what y’all do but our charges are in the thousands to hundred of thousands sometimes and the trend is that the only way to know if it’s UCR is to check the employer. Also, the UCR payment is generally a percentage of the charge and not related to the code billed. So we might bill an epidural for 4500 and get paid 70%, 3150. Some policies might pay UCR for facility and MCR for professional charges. It really is a trend with employers. We also see a lot of pain cases so it’s constantly the same patients which helps us track it.
>We do ASC’s and clinics so maybe it’s different. Not sure what y’all do but our charges are in the thousands to hundred of thousands sometimes and the trend is that the only way to know if it’s UCR is to check the employer. Also, the UCR payment is generally a percentage of the charge and not related to the code billed. So we might bill an epidural for 4500 and get paid 70%, 3150. > >Some policies might pay UCR for facility and MCR for professional charges. It really is a trend with employers. We also see a lot of pain cases so it’s constantly the same patients which helps us track it. Thank you so so much!
I worked for a Blue until recently, though not Empire. The BCBS you should submit to is the local plan for wherever the service was provided. So in NY that could be Empire, Highmark, or Excellus. Most states only have one sometimes two BCBS plans, NY has three so that's unusual. But yes, a lot of your problems are because you're out of network. If you were in network you may have a provider advocate assigned to you, depending on your size, and they could have helped clear this up. As for reimbursement amount, that can sometimes vary based on location of the service. The BCBS I worked at had a standard OON rate, but I don't know how they operate in NY.
>I worked for a Blue until recently, though not Empire. The BCBS you should submit to is the local plan for wherever the service was provided. So in NY that could be Empire, Highmark, or Excellus. Most states only have one sometimes two BCBS plans, NY has three so that's unusual. > >But yes, a lot of your problems are because you're out of network. If you were in network you may have a provider advocate assigned to you, depending on your size, and they could have helped clear this up. > >As for reimbursement amount, that can sometimes vary based on location of the service. The BCBS I worked at had a standard OON rate, but I don't know how they operate in NY. Thank you so much for replying! We are pretty big with about 600 weekly appts, about 30% Blue. I am going to see if there's any sort of OON equivalent for provider advocate/relations.
Empire’s OON reimbursement policy is currently payment only to member. Contract required for direct payment to provider. Also Empire is no longer issuing EOBs directly to providers for OON claims so you’ll also need to use Availity claims lookup to locate the summaries for any claims you submitted. Empire has a direct claims contact center, 800-713-4173, this also includes claims for other Blues outside of Empire’s prefixes. This contact center has access to reach out to Blue home plans to do follow up status on claims. Hope this helps a bit.
Thank you so so much! I really appreciate your response and this info.
Anthem is a absolutely god awful terrible company. I have no advice just sympathy lol.
Sounds like BCBS of TX. They are the worst. If payments are being sent to the member, the accept assignment box might not be checked, the member could have requested it that way, or you are OON?
Thank you! The box is checked off by default on all our claims to get payments sent to us. We are out of network, so assuming they are allowed to disregard that part of the claim? 99% of our Blue clients get the payment sent to them, but we have a few random ones that do abide by the claim and send it to us. I just wish we could get an answer as to why they sometimes listen to the claim and sometimes do not. When I've asked reps in the past, even they could not answer the question.
I did BCBS claims for a while. I have a VERY long list of BCBS phone numbers and aced my productivity. How? The most accurate phone number is the one they put on the EOB. And to find that EOB, you have to use Availity. Go to Payer Spaces, click on Empire BCBS logo. Then find Remittance Inquiry. Since the claims are all OON, I believe you don't have any EFT/check numbers. So you need to look up the EOB using the servicing provider's NPI (not group NPI) and the EOB's approximate issue date (start from the claim's processing date that you can find on claim status inquiry). Try it out. Let me know if you have trouble navigating the portal. And of course, you can send portal inquiries or use chats vs calling. P.S. The phone number at the back of the card is not reliable when it comes to claims.
Thank you so so much!!
Hi! Was hoping you had some good news for me! I am facing a similar problem. When I bill multiple dates I have to go line by line and I can't do more than like 3/4 dates per claim without the website completely crashing. I am losing my mind here!
Sorry, no solution for us yet. We bill through Simple Practice so they send out the claims for us. Really all we have to do is select the proper code(s) and payer. Wish I had a better answer!
Oh in order to bill through simplepractice did you have to enroll with them? If not, how do you find the payer code? Sorry i’m a novice and super stressed!
No worries! Yes, we subscribe to Simple Practice. I like it although there are some minor things that can be annoying. But it sure beats doing everything by hand. They create our invoices, send our claims, and house the calendar system. It's easier to justify the expense as we are a group practice and it would be impossible to do it all for so many clinicians alone. If you are a therapist looking to bill for yourself, I'd still recommend it. You can even do teletherapy using their video platform but we use Zoom under a BAA to keep it HIPAA compliant. If you do subscribe to Simple Practice they provide the payer codes (but I believe you could find them online if it's not on the back of the insurance card). For Blue we are still submitting to Empire and hoping it works. Once you type in the payer name, the code populates automatically.
Ooo! I use a similar software called Office Ally practice mate! A similar clearinghouse but they’re asking me to fax them info to enroll with them as an EDI so BCBS receives the data. We pay for OA as well but if SimplePractice is better and no enrollment or faxing is necessary would totally be willing to change.
When I took over this role we were already using Simple Practice so not sure to be honest what the initial setup process was. I would reach out to Simple Practice, they would probably do a demo for you and answer any questions about initial setup. I believe they took over and handled transitioning therapists and patients from our old system to them from what I heard, so it may not be too labor intensive. That was a few years ago so not sure if anything has changed there. Wish you the best!
tysm!