Billing Insurance: Getting Started

Editor’s Note: Even if you’ve been billing insurance for years, this article applies to you. Make sure you understand your rights and responsibilities regarding choosing insurance plans, joining plan networks and billing Medicare.

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Question: I am a new provider and want to bill insurance. What are my requirements to get started?

Congratulations, and I am certain you are excited, but also a bit intimidated about starting. Your question is common and there is a great deal of misunderstanding (even among seasoned insurance billers). New providers often mistakenly believe they must sign up to bill insurance, which in fact is incorrect.

Once a provider is licensed, they may begin practicing and may bill insurance for their services. There is no requirement to sign up for any insurance plan to begin billing insurance, but simply that you are willing to provide your services and in turn, bill insurance.

Basic Requirements

Of course, you must be licensed and have set up your national provider number (NPI), but that was likely done while you were working in the clinic of your school. You must also have a tax identification number (TIN), but this may vary depending on how you are set up. It could be as simple as your social security number, but that is not recommended, and it is better to set up a tax ID under your business and not just as an individual.

Choosing Insurance Plans

Keep in mind it is always an individual choice and billing insurance is not “take one take all.” You may choose to accept some plans and not others. (It is common for medical practitioners to indicate that they accept insurance, but not state they do not accept all insurance.)

You may choose to accept not only certain carriers, but also certain types of plans. For example, if you bill Blue Cross Blue Shield, you have the option to accept only certain plans under BCBS and not others.

Enrolling as a Registered Provider

Providers have a right to choose which plans they accept and which they don’t. However, that also means you are not in the network with the plan as a registered provider. If you do enroll with a particular plan as a provider, you then have an obligation to bill and cannot choose not to do so.

In terms of your question, this may be partly what you are thinking, in that some insurance plans will have benefits only with providers who are part of their network. For these plans, you would need to register as a provider within the network. But before leaping, I would always look at the global outcome of that relationship.

In-Network vs. Out-of-Network: Important Factors to Consider

You may be confused by the fact that there are certain plans with only “in-network” benefits. This type of plan is offered by a health maintenance organization (HMO) and these plans will not pay a provider who is not registered as a member of their plan.

Outside of this type of plan, whether it be a standard indemnity plan or even a preferred provider organization (PPO), once you are licensed you may access and bill for your services.

So, the first factor to consider is: Does the plan limit benefits to only “in-network” providers? Many plans offered by preferred provider organizations (PPOs) will allow patients to choose providers out of the network – but the out-of-pocket expense to the patient may be higher. The incentive is that when the patient chooses an “in-network” provider, they may have only a copayment or at least a lesser out-of-pocket cost.

But what is interesting is that some plans will allow and pay more to the out-of-network provider (albeit some of the payment will also be placed on the patient). But we have to take a look at this from a business standpoint. Will the lesser payment be made up with greater volume or will you continue to see the same number and just be allowed to bill for less?

My basic rule is this: Don’t join any plan that will pay you when out of network. Why? Because I find patients will often choose the out-of-network provider based on the reputation of the provider, not solely on price. Unless you can assure a greater volume and your office procedure efficiency can accommodate, why take less money? You will still be paid, but it will not be limited to the contracted rate.

There are several factors to consider, but this to me is the one of greatest value.

Understanding Medicare Registration

The only plan I recommend you should join is Medicare. As a chiropractic provider, you must belong to Medicare as a registered provider, whether “participating” or “non-participating,” in order to treat a Medicare patient. This is due to the mandatory billing requirement by Medicare whereby only registered providers may bill.

Therefore, if you choose to not register for Medicare, that is your choice, but it also means you will not be able to treat a Medicare patient, as the mandatory billing requires you bill for any spinal manipulation service. Do not confuse “non-participating” as not registered; and understand that there is also no “opt out” option for doctors of chiropractic.

Take-Home Points

I recommend being selective and certainly accepting plans that will pay for your services, as any time patients are better able to afford your services, the more likely they will be to solicit you for care. However, you need not join any plan when starting, and can take your time deciding, based on your region and patient base, whether joining a specific insurance plan’s network will be of benefit.

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Editor’s Note: Have a billing question? Submit it via email to Sam at sam@hjrossnetwork.com. Your question may be the subject of a future column. Note that submission of a question is acknowledgment that it may be referenced (anonymously) in his column.