Billing Resources Q&A

Have a question about billing services at your organization or how to conduct a cost analysis? Use the Ask-the-Expert function below to submit any questions you have related to billing, and one of our experts will provide you with an answer! You can also browse previously submitted questions and answers.

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Previously Submitted Questions and Answers

Question: What are in-kind contributions?
Answer: In-kind contributions include volunteer staff time and/or donated goods. They need to be included for their equivalent cost when conducting a cost analysis, even if they are currently donated to your organization.
Question: How can RVUs/CPT codes be used in terms of setting up billing with other agencies?
Answer: They are good for setting a fee for your services, but may not be true to your costs. When negotiating with larger payers you might be bound to use rates set by RVUs and CPT codes, but when negotiating with another agency you have more flexibility and it is ideal to cover your costs and make a small profit. That said, it’s good to know the rate reimbursed by Medicaid and, if possible commercial payers, to compare with your costs and help you determine a “fair” fee.
Question: How do the results from a cost analysis relate to Medicaid/Medicare reimbursement rates? Can you justify exceeding Medicare/Medicaid rates?
Answer: Medicare and Medicaid reimbursement rates are set by the State Health and Human Services department (Medicaid) and the federal Department of Health and Human Services (Medicare) and it is very hard to change these rates. It’s important to conduct a cost analysis for appropriate strategic planning given that these rates are established. You conduct a cost analysis to determine your organization’s true costs for conducting a given service and compare those with the reimbursement rate for Medicare and Medicaid for that same service. Then, depending on the difference, you can look at what other billing services to establish. For example, if your true costs are higher than what you could get reimbursed under Medicaid, you might consider also billing private insurance companies.
Question: Where should we place administrative staff?
Answer: It depends, if the administrative staff is helping directly to provide the service then you would include them under direct costs. If not, include them under indirect costs and use an indirect cost allocation method to determine the percentage allocation for those services.
Question: How does cost analysis relate to Medicare/Medicaid reimbursement rate? Can you justify exceeding Medicare/Medicaid rate?
Answer: Medicare and Medicaid reimbursement rates are set by the State Health and Human Services department (Medicaid) and the federal Department of Health and Human Services (Medicare) and it is very hard to change these rates. It’s important to conduct a cost analysis for appropriate strategic planning given that these rates are established. You conduct a cost analysis to determine your organization’s true costs for conducting a given service and compare those with the reimbursement rate for Medicare and Medicaid for that same service. Then, depending on the difference, you can look at what other billing services to establish. For example, if your true costs are higher than what you could get reimbursed under Medicaid, you might consider also billing private insurance companies.
Question: How can RVUs/CPT codes be used in terms of setting up billing with other agencies?
Answer: They are good for setting a fee for your services, but may not be true to your costs. When negotiating with larger payers you might be bound to use rates set by RVUs and CPT codes, but when negotiating with another agency you have more flexibility and it is ideal to cover your costs and make a small profit. That said, it’s good to know the rate reimbursed by Medicaid and, if possible commercial payers, to compare with your costs and help you determine a “fair” fee.
Question: Can we charge clients co-pays based on the sliding fee scale if they don’t have insurance?
Answer: I think this depends on how you are using the term “copay.”  Most often a copay is part of the charge that the client’s insurance contract determines is their responsibility.  For example, a client pays a $25.00 copy every time he visits a doctor.  When talking about sliding fee scales, however, the word copay often takes on a different meaning.  In this instance the copay is the portion of the full charge that the client is asked to pay based on where they fall on the sliding fee scale.  For example, if a client has no insurance and falls on a sliding fee scale at 50% of full charge, then if the visit is $100.00, the client’s copay would be $50.00.
Question: How many ICD codes can one bill for in one visit?
Answer: You can bill for a number of ICD codes. It doesn’t really add to your reimbursement. Most important this is to match your ICD codes with CPT codes.
Question: How many CPT codes can one bill for in one visit?
Answer: CPT codes are for the procedures you have done. You can include as many CPT codes as you need to in order to reflect the service you provided.
Question: Can you review codes used for time counseling related to diagnosis? For example, discussing safer sex, medication adherence, and stigma related to living with HIV?
Answer: You can use an E&M code if more than 50% of your time is spent on counseling with licensed provider. The other way is to use the counseling code.
Question: What are the implications of being a classified Essential Community Provider?
Answer: A qualified health plan that’s part of a marketplace, needs to contract with a specific amount of essential community providers. If you’re an Essential Community Provider and you’re on the ECP list (from the Centers for Medicare and Medicaid Services) your chances of contracting with a health plan are a lot higher.
Question: Can you collect copay from a patient with insurance if you’re an out of network provider?
Answer: You can and you should. If you have the ability and know what your patients’ copays are, regardless of whether you’re in network or out of network, collect it if you are able to.
Question: Is it standard to deny service if the client does not bring a co-pay?
Answer: It is not standard. That is part of an organization’s financial policy. You can decide to not treat, and some medical practices do this if you don’t bring your co-pay at the time of service they won’t see you. But it certainly isn’t standard. That is really a strategic decision that needs to be made by each organization.
Question: If your provider is contracted with insurance but he’s not on site when services are rendered, can we bill for the nurse who provided the service?
Answer: That does depend on your service, and it also depends on the type of contract that you have with the insurance. We talked about the contracts where they are grouped based on an entity, so the contract is with the organization, and all of the providers are covered or listed on the contract. So it really depends on the services that are provided, whether a nurse is qualified to provide those services, or not, and also what type of contract you have with that insurance company.
Question: How far back can you retroactively bill, and also, how long do prior authorizations usually take?
Answer: Retroactive billing depends on what the insurance company outlines in their contract. Some insurance companies allow, say, 90 days to submit a claim, and that’s referred to as timely filing, you have 90 days to submit a claim. If you do it at the 91st day, it’s out of timely filing, and they won’t process the claim, or pay for it. They are the payers that have up to 365 days to submit a claim. So that really depends on the plan. If the question is how long it takes, most companies have online systems that will allow you to request preauthorization through their website, and it’s secure, and that could take us as little as 15 minutes. Other companies required a telephone call which could take at least 30 minutes to get through and get that preauthorization.