Welcome, everyone, to the webinar, The Basics of Managed Care, What You Need to Know. We're so glad you could join us today. With more and more consumers presenting some form of hearing aid coverage, whether discount, comprehensive, or otherwise, it's becoming critical to understand the basics of managed care participation. Your moderators today are me, Diana Cherevil, Associate Director of Marketing. And me, Priyana Vincent, IHS Director of Marketing and Membership. Now, on to our speaker. We do regret to inform you that, unfortunately, due to poor weather and delayed flights, our co-presenter, Samantha Sikorsky, ACA and owner of Sikorsky Hearing Aid Center, Inc., and Chairperson of the IHS Managed Care and Compliance Committee, will no longer be able to join us today. However, we are in the very expert hands of Joe Bartlett, ACA, BCHIS, and owner and CEO of Bartlett's Hearing Aid Centers. Joe is a third-generation owner and CEO of Bartlett's Hearing Aid Centers in Northern California. He started in the industry in 2002 and received his ACA certification in 2014 by IHS, and has been a proud member and supporter for the last decade. Joe took over as CEO in 2010, and has grown the business to four locations that fit more than 1,000 hearing aids per year. Joe is also a member of the IHS Managed Care and Compliance Committee. We're so excited to have Joe as our presenter today, but before we get started, a few housekeeping items to keep in mind. Please note that we are recording today's presentation, so we may offer it on demand through the IHS website in the future. Also, this webinar is available for one continuing education credit through the International Hearing Society. We've uploaded the CE quiz to the handout section of the webinar dashboard, and you may download it at any time. You can also find the quiz and more information about receiving continuing education credit at our website, ihsinfo.org. Click on the webinar banner on the homepage, or choose webinars from the navigation menu. You'll find a CE quiz along with info on how to submit your quiz to IHS for credit. If you'd like a copy of the slideshow from today's presentation, you can download it from the handout section of the webinar dashboard as well, or you can access it from the webinar page on the IHS website. Feel free to download the materials right now. And tomorrow, you will receive an email with a link to a survey on this webinar. It's brief, and your feedback will help us create valuable content for you moving forward. Now, we've got some disclaimers to add. This seminar has been prepared for informational purposes only. Our presenter is not an attorney, and nothing in the presentation should be considered legal advice. If during the course of this presentation you have learned that you may have committed insurance fraud, please seek legal counsel on how to proceed. This presentation will also give you a great overview and touch on the basics of managed care. If you want a deeper dive, we urge you to pick up the Guide to Third-Party Participation in the IHS store on our website. It's 70 pages offering advice on managed care, including sample forms and letters. And it's free if you are an IHS member. Today, you're going to hear our presenter talk about the importance of a compliance plan when working with a health plan. So keep an eye out for the Compliance Plan Template in early 2020, produced by the IHS Managed Care and Compliance Committee. It's an extremely valuable tool to help businesses with their legal compliance. And required by health plans for network participation, a ready-made compliance plan would pay the cost of one's membership. And finally today, we will be covering the following topics. What is managed care, participation requirements, legal considerations, and the billing process. And at the end, we'll move on to a Q&A session. You can send a question for Joe at any time by entering the question in the question box on your webinar dashboard, usually located to the right or top of your webinar screen. We'll take as many questions as we can in the time we have available. And now I'm going to turn it over to Joe, who's going to take us through today's presentation. Joe? Thank you so much. I'm very excited to present on this today. It's something that I feel like I deal with on a daily basis in my own offices and I've trained numerous staff members to be able to get through the pitfalls of some of this. So we're going to be covering a lot of the basics today. So it gives you kind of a launching point to decide if this is something that you want to work with. So our first topic we're going to cover today is what is managed care? So managed care is this buzzword that we hear all over about that pertains to insurance billing. So the first thing we have here is in its basic form, it's the managing of cost, utilization, and quality. So when it comes to cost, it's the pricing that the insurance companies want to be able to regulate and control. They want to make sure that it's controlled for their own bottom line and they want to make sure it's controlled for their members' bottom line. Utilization is something you should think of when it comes to the structure of how the delivery happens. How does a patient get the services that they need? Prior to utilization, physicians could order any test without the regard for a patient's need or even their pocketbook. And now it allows payers to employ a diverse group of professionals that evaluate whether that physician, if the recommendation was even necessary. And then the third one is quality. This is basically done against standards of the delivery of that practice. So they want to make sure that they have providers that are credentialed, that they're contracted, that they're good quality providers for these services that are being rendered. Medicare, if you've been on the planet long enough, you're going to have heard the word Medicare. It's in its most basic form. It's for anybody that's 65 and a half and up. There are some Medicare benefits for those that have disability or disease that may be in a younger age group. But for the most part, what we're talking about today is going to be the 65 and a half, basically, and up. So there's part A. That's what everyone becomes eligible with when they're over the age of 65. It's funded through payroll taxes. So throughout the years, if you paid your payroll taxes, that money goes into funds, and that pays for the part A type of catastrophic and emergent care. Part B is more for diagnostic and outpatient services. It's something that is optional, and usually it needs to be signed up for, and there's a monthly co-payment for participation. Part C is something we have with a managed care organization option, or MCO. Medicare services are usually private. They're farmed out to these MCOs, and some of these do pay a portion of hearing aid services if it's something that was negotiated into their contract. Now, this, I've found, can be regional. There are some larger groups that are out there that are offering hearing aid benefits, and usually it's going to fall under this sort of a program, but we'll get into today about ways to sift through and figure out if there's anything there. For part D, it's mainly gonna be for prescription-type benefits. Okay, well, how are providers compensated? This is one of the big reasons why we wanna take insurance is to somehow be compensated. So it's good to know some of the reasons behind why we do what we're doing here. So the first thing, well, patients are accustomed to going into a physician's office, let's say, where a physician writes a referral, orders a letter, and does several different services on their behalf, and they never see a charge for it. That is something, if you see on the right, called capitation. The practitioners are actually paid for having patients under their care. So they are getting reimbursed, but it's more of a monthly or something in their contracts that say how that they should do it. In our offices, we work more for fee-for-service, where we have to do a line item per billing, per item sent to the insurance company, and we either are going to be reimbursed by that insurance company, or it has to actually go to the patients themselves. So patients get surprised when they go to an unbundled facility that charges them for the time or services. So you should consider how you're gonna handle the needs of these type of patients if you're using a fee-for-service model, because insurance carriers, they often won't compensate you time for writing a letter to an insurance company. I'm sorry, for a patient to their physician. This often includes sending like a fax or the hearing test that was done. It's often something you're not going to be able to bill the insurance company for. You'll have to bill the patient directly for the time it takes to write a letter or send your hearing test on to the patient's physician. There's a fee schedule versus a charge master. So insurance carriers set a budget to determine what they will pay per code. Now this is regardless of the cost to you or your company or whoever's performing the services. So you should know that whatever service you offer, as well as the cost of your company for providing such services, you have to know the number, or it has to be written out in the contract. So looking at this specifically, your insurance company would say for this assessment of tinnitus, that they in the contract would only pay $28 for something like that. You have to determine if that's enough for you to earn for that service. So if you look at the charge master, if you break down your hourly cost and that process takes 15 minutes to do and you have a $200 an hour cost to run your business, well, that means that you need to be reimbursed $50 somehow to order to break even on your break-even analysis to break even, otherwise you're losing money. And if you can't write off to the fee schedule in that contract, you have to determine whether you can be a part of that contract. And often that's something that's done in the negotiation process. So again, these are separate things. You should know what your break-even costs are before you even enter into any of the next steps that we're working with here. Okay, participation versus non-participation. Kind of cut and dry. If you participate with any of these listed items, then you're taking insurance basically. If you do not take any of them, then you're a non-participation. That what I really like to clarify is the difference between these is if you're going from a non-participation entity to a participation entity, you have to look at your cashflow analysis of your business because as soon as you do start taking insurance, you will see a hit because the payments are now pushed 90 days, 60 days, something like that, depending on the contracts or the company, down the line. Even a true hearing or an EPIC group, I think it's 45 days before they'll pay you. So you have to make sure that you have enough either cashflow on hand or lines of credit, or even discussing with your manufacturers that you're going to be changing because their credit lines have to be able to match what you're working with, or else you'll come across a pretty serious cashflow issue when it comes to this. None of this has to do with being in network. We're going to get into that in just a little bit here. In fact, one slide later. So there's two different things, being in network or out of network. And really the basic part of that is an in-network provider is going to have a contract. You're going to have it be spelled out of exactly what the rule books are, what you're allowed to take, whether you're allowed to balance bill or not. Some of the benefits of that is you're going to see an increase in referrals from the insurance carrier to you. You'll be listed often on a website, or you'll be listed in a list of providers in your area. And if somebody goes to their insurance and says, who do I go to for hearing aids? You would pop up. So that's the benefit of being in network. The out of network side of it is you're not tied to all the contractual obligations. You can collect, if an insurance company pays you the out of network rate, there's very rarely, if ever, a balance billing issue where you can't collect the difference between what the insurance pays and what your breakeven analysis on your prices are. Okay, so I've gotten through a few of the issues of just the overlying things that are out there. So let's talk a little bit about just getting started. So the first thing you're going to want to do is make sure that you are set up with a national provider identifier or an NPI number. This is unique. You can think of it as it's like your social security number for your business. It identifies you to all insurance carriers that are out there. Your tax ID number is often something that's used as well, but it's not used when you're doing billing. So you want to make sure that you have a national provider identifier number. And you can see we have a link provided where you can go on and register. Now there's two different types. There's an individual NPI that each provider in your office should have. And that registers that provider. If anybody that's going to be providing a service that's billable should have an NPI number. Then you're going to also have an organization NPI number. It should be your global number. And there's different places that all goes on your billing form when it works with it. So you should be able to register both of those. Now, a taxonomy code, there is a list of all different professions that are out there. And the code for an audiologist, as you can see, is the 231H and it ends with the zeros and the X. And hearing instrument specialist has a taxonomy code as well. And it's the 2377 and all the zeros and the X there as well. It's a way that insurance companies know. Now, an audiologist is going to be able to bill for different services because of their scope of practice versus a hearing instrument specialist. So that's often depicted as underneath those different taxonomy codes by the insurance company. Okay, registering versus credentialing. So the first thing that you would need to do with an insurance company that requires it is credentialing. It can be a little arduous. They're often want to know all of your licensing information, whatever's required in your state. I've seen them come down to making sure that your audiometer calibration is up to standards. Some can even ask for compliance plans, which we've alluded to a little bit and the Managed Care and Compliance Committee is working with helping people get templates for that type of a thing. So credentialing is, they're going to give you a list of things they want you to do. So each carrier can be a little bit different and it can take a while. I know Medi-Cal or Medicaid in California can take up to a year to get credentialed with them. So if you were planning on taking Medi-Cal or if you were planning on taking Medi-Cal or in California, you probably won't see a penny come for a year because of the credentialing and contracting process that happens. Now, registration is just a little bit different. Often the companies that you have credentialed with will have a payer ID number. And if you do go to, you can even ask what their specific clearing house is. I know Availity is a big one. Availity.com is a big one that's used. You've got to use that payer ID to clarify that specific carrier. Just because, well, if you're not in, if you're not credentialed with a provider, they may still have registration that's there too. So you always want to just check with any group that you're billing and make sure that they have an online clearing house where you can check eligibility, billing and payment information. Often they will allow electronic billing, but you do need to know what the payer ID is to be able to work with that. Contracting. I think if any of us have ever signed a contract, usually there's lots, it's just a often boilerplate, but then you want to make sure you look at all of the details. So when it comes to insurance company contracting, it's no different. You want to make sure that all of the fee schedules if available would match your office's processes. So if you have, this is a CAQH number. If you do have a CAQH number, often it's a little bit, it can be sped up. There's cases I've known where it's made it quicker and I've had some carriers that say they don't take it, but if you go all onto the website where you can register for CAQH, it just asks you every now and then to update your liability insurance or your licensing, making sure you're continually be licensed. A W-9 be something that you should kind of have on hand anyway, but it is a way that you, the insurance carriers that are paying you can keep track of the money that they're paying you. So often if you haven't worked with an insurance carrier in the past, be it contracted or not, if it's the first time you've worked with them, you should include your W-9 in your first billing because they're most likely going to ask you for it anyway. Anything that's a disclosure, something that needs to be done. Negotiation is something that is, if you're, there's negotiation tactics that's in our workbook that we have. And it's, you need to be ready to do some negotiation if you're going to take insurance at all. And that you want to make sure you're continually fighting to get your best payout on what you're working with. I actually have great staff members who I call them bulldogs and I know Samantha, she says she's a bulldog as well. You have to be able to be a bulldog to work with this sort of stuff. And then often if there's larger insurance agencies through physicians plans, they're going to be doing the global billing when it comes to working with the insurances. You might not actually even work directly with the insurance company, you might work with more of an agency that's in the process of that. A few warnings here. The one warning that I can't stress enough and I know that being on this committee and working with Samantha has been repeatedly said is read your contracts, know your contracts because out of the blue, something's going to happen on a billing. And you want to make sure that everything comes down to the common denominator that it's in that contract. So if you get a denial for a billing, let's just say we're past the point where this is, you get a denial for a billing and they ask you for an invoice. You want to make sure you're never, never, ever, ever submitting your lowest price on that invoice, what you're paying the manufacturer. Do not give that to insurance carriers unless it's spelled out specifically in your contract that that's how you get reimbursed. For an example, I've been asked by Anthem Blue Cross numerous times to provide an invoice because they wanted to clarify the coding that we were using to make sure that we were providing the product that we're billing for because codes are specific, but never did they want the price. So we provide the packing list that had the date of purchasing. It had the serial numbers, the type of product, the manufacturer. Now, when we work with state Medi-Cal or Medicaid, our contract says they will pay X amount over our single unit cost. So we have to provide our invoice with our single unit cost in order to be reimbursed on that. So just make sure if you take something away that never provide your lowest cost and what's in your contract specifically stating that's how you're going to get paid. Advertising. Lots of us have evolved. I know my company's been almost 50 years, so we go back to the days of all sorts of fun gimmickry in advertising. If you are going to start taking insurance, you have to take a look at all of your advertising to figure out what's going to happen next. Discounts versus incentives. If you advertise a discount and you don't specify it doesn't apply to insurance, then it applies to your insurance patients. There's the old 50% off MSRP everybody used to use. Well, if you're providing 50% off MSRP to a private pay patient that is not using insurance, you need to be providing the same 50% discount to the insurance company when you're billing as well. There's pretty much anything you put in writing, you have to be willing to give to the insurance company unless you specify that it's not there. And I use the example of Medi-Cal in California a lot because of the way that that contract is specific. If we do some sort of an incentive or some sort of a discount that we advertise either our direct mail or TV or newspaper, whatever, we have to state this does not apply to Medi-Cal and it's the process is the way that works. There's nothing wrong with providing incentives for someone who pays either cash pay, same day, pay in full, you can give a discount for those sort of items. Even whether you're advertising or not, you are able to give a discount for that. Now, the Office of the Inspector General, they do limit your discounts to 15% and they apply to a federal type of billing. So if you do a lot of federal insurances or you start doing a lot of federal insurances, you wanna be very careful to keep your discounts to a limit because that is under their jurisdiction and they do have a limit of how much you can discount for it and a lot of this you can look further into some of our resources to ask about that as well. This is one of the most common things that's happened, the free hearing tests that are always put out there. Free hearing screenings have been now the big change to say, well, I know in California, if you say free hearing tests, you have to say to determine your need or to determine need for hearing aids. So if you change to a screening, that's been often the change so that people get away from having to say that. Well, you have to be careful because if you are still just doing a full hearing test, then technically you've set a precedent that you're doing, basically doing a hearing test. Now, it's important to determine what does this mean? So if you sit down with a patient and you do a hearing screening and you stop because you see that there is hearing loss, so you've done maybe a few points, you followed some basic protocol, your office says this is a screening and you stop and tell the patient, okay, we see hearing impairment, we're going to move on to the next step. You have to determine what your charges are then for that. If there's something that you're going to be billing the patient for it and if you're not billing the patient for it, you can't turn around and then bill someone else that walked in the door. So often this happens with some of the third parties that do allow like a true hearing that allows you to charge a patient 45 or $75 for a hearing test. If you're not charging anybody for a hearing test, you can't charge that person for a hearing test either. Now, if it's a difference in its consultation or something where you were able to clarify the differences, it's something that you can consider if you want to live in the gray areas that are there, that's often someplace to hang out. Okay, we have our participation. So we talked about this just a little bit earlier. So you might be ready now and you might be completely compliant already in regard to insurance, but that all starts to go out the window when a patient then walks in your door and starts giving you an insurance card. This is how we're going to basically talk about how to verify coverage and how to discuss how you're sharing costs. We're going to take a deep look at how to interact with patients regarding their coverage. Okay, so our first step is determining eligibility. First thing you want to make sure is that A, the patient's policy is eligible on that day. Just because they hand you a card doesn't mean they have a current policy at all. Often even the cards don't have a expiration date on them. So it is important that your processes include somebody contacting the insurance company and getting an eligibility. It's best not to offer a lot of guidance around what the coverages are. And specifically, you shouldn't be fitting hearing aids based on coverage. There's common pitfalls that happen with that. Specifically, if someone comes in and you get eligibility, they say that they have 100% coverage and you turn around and you say, well, I'm going to fit from our price list, our best and brightest product with no discounts, you throw it out there and the insurance company comes back and pays like 50% of what you thought they were going to pay. And now you've told the patient that there's 100% coverage and it gets very, very, very messy. So the best thing is to not offer guidance, but to fit the patient with the hearing aids that they need and make sure that they understand, and there's even forms that should be taken care of at the beginning, that they are responsible for all of the costs. You're just billing their insurance as a courtesy. That usually gives you a very wide open, honest answer. And this example here, if they have not met their deductible, you can see that where it says $2,000 deductible, $0 met, they may pay nothing. And that patient now thinks that they're going to have 80% of that covered for them. And now it gets really sticky in the long run of now having to backtrack and say, well, that's not what I meant, and now we have to bill you. There is a questionnaire that we use that you should definitely adopt if you're working with insurance. And this spells out the full phone call. What's the person's legal name, date of birth, gender, all of those things are on there, whether you're in and out of network with that specific provider. And I won't go through all of the different categories, but one thing that is extremely important is a reference number. Often these insurance companies are recording the phone call that you're having with them, and they give you a reference number at the end of that call. And it should be 100% of the time that you're getting that reference number. Often I've had to go back when insurance has denied a claim because of something they said of like prior authorization, something that medical clearance, and they didn't say anything about that. And we asked them specifically in the phone call, and we've had to go back and say, listen to this call. And we've had it turned around because we had the reference number and we were able to say, listen to this phone call. This says you never said that we asked you specifically, you in fact said, no, that's not required. So you have to cover yourself very well. Further in the process, and this again comes down to that idea. I really say create a case when you're working with this. The part starts out with having an audiogram with the notes, your case history. So you wanna be very, very specific as to why you're telling this person that they should have hearing aids in the first place. You should have an authorization if it's required. You should have an authorization to bill the insurance in the first place. So that's one of the things that I was describing just a bit ago, getting an authorization to bill. Also, it's the authorization to be able to bill the patient after the fact, because they understand they're giving you permission to bill their insurance, but they also understand that they have a responsibility if insurance does not pay. The authorization to pay, this kind of goes both ways. So that's the patient, sorry, the benefits by the insurance is the property of the patient. So that means that they're telling you, telling the insurance to pay you the money. There's an authorization from the insurance to actually bill them as even a third thing. Like I was saying, the medical necessity or the just authorization in general, if you're required to get that and you find that out from the previous call, you wanna make sure that that's something that's being provided when you're doing your billing. If you are in contract, there's something that are called upgrades. And often it's something that a patient may or may not be aware of. If you're in network and you're in contract and your coverage is, let's say a $2,500 coverage and the patient wants to buy $5,000 worth of hearing aids, that's an upgrade. And there is specific things that need to be done. We're not gonna get into all of that today for it. It's a little more advanced and I recommend reading in the manual of a few things. There's definitely a section already on that, but you can't just bill the patient unless your contract allows you to, otherwise it's called balanced billing. But there are codes that can be put in saying that you've had that conversation. So before you just start sending bills to patients, make sure you've read your contract very carefully. Next step here. So submitting a claim, what I've written on all of my notes to work with is be very specific. So the demographic of a patient, you want their name, obviously address, date of birth, gender. Those are kind of some obvious things, but if someone's name is Buck Rogers and its name is really Barry Rogers, don't have Buck Rogers on the form. You wanna make sure it's very specific to what the name is on the insurance card. I've had people that have similar names and my staff got a little bit quick and they messed up something and ended up being denied down the line for something silly like that. So be very specific and take your time. Spouses, in a lot of cases, as it says here, the spouse may be the member. They need to be listed on the insurance claim form as well. And they may not even have the same address. So you wanna make sure that, again, being very specific. You should never treat insurance like it's just a process that is just repetitive, repetitive, repetitive. Every claim needs to take time and line by line, make sure that somebody's going over it and that you're taking care of all of the differences between each of the patients you're working with. Some insurance plan numbers, everybody's gonna have a member ID number, often there's group numbers. I discussed a little earlier, but this is where you would also wanna know the payer ID for the company that you're working, that you're going to be billing as well. Diagnosis codes, if you've gone down the HCFA 1500, the red forms we work with, there's all sorts of spots where you start putting codes in and start working with that. This is just a little overview of what those mean. There's further of a deep dive as to which codes to use on different things. But again, I wrote down myself a note, be specific. And I use that with all of my staff in describing this, be specific. If you're using a code, an ICD-10 code, and the person has a specific condition, you can put down the specific code to that condition. Now, make sure you have documentation in your own notes as to why you feel that way or why that is your opinion, but use the code that determines it. In the past with ICD-9, we all just wrote 389.1, and that was hearing loss or sensorineural hearing loss. You can't really do that anymore. And if you do, then you leave yourself open to someone saying, well, you're treating something that that's not what the person has. So be very specific, look at your codes. Often there's a list that you can go through and see, but be specific. Down to your HCPCS and your CPT codes, same idea. If you provided, if there's an air conduction test and that's all you did, and that's what the insurance pays for, and you bill, you should get $28. And if it's full evaluation, you're gonna get 48, but you don't just bill a full evaluation if you only did air conduction. So you wanna be very, again, very specific as to what's going on. If you're fitting one hearing aid, and there's a difference in the codes for the insurance company, as you can see, between a monaural code or a binaural code, you can't just bill two monaural codes to make it up. You have to be specific to what happened. And the codes are, the HCPCS and the CPT codes are very specific to be able to work with that. For your date of service, that's going to be the date the product was actually delivered. And this is something that I've really learned in getting into this committee and really cleaning up my own compliance programs and making sure that we are up to speed is that we don't ever bill unless the product is delivered. We were following our contracts in the past and some contracts specifically state this, but if it's not stated, we're still following that it's at the delivery. Often the in-trial idea, you have to read your contract again. Some of them do say you can't submit the claim while the patient is in trial. Be sure to know if that's the case. They may want you to use, again, the same date of service, but not to submit the bill until the trial is done. This is actually a great asset to have here. And I think it's in our manual as well, but we have a checklist for submission. These different things you should have when you're doing your submissions of your insurance, all of these should be followed line item, line item, line item, before that goes into either the electronic billing, scanning into the mail. This should be looked over that all of this has been put on the form. All of the appropriate forms have been attached. Documentation is necessary. So take your time. You'll be happy that you took your time on the front end of it, because in the long run, denials can make that payment go from a 30-day to a 60-day, or a 60-day to a 90-day, or even longer. I've seen claims take up to six months to get paid before. And sometimes it's just the insurance companies kicking the can down the road because they found one tiny little minute detail that you did incorrectly. So follow forms, get that done correctly. This is one of my favorite things to work with. And I think that, I don't wanna say this is a takeaway, but if you've ever gotten a call or an email or a fax from a claim negotiator, the insurance companies, they employ these, especially if you're out of network, they try to cut the price down. So again, you're billing your price. You figured out what your lowest common denominator is, like what you need to make. And your pricing should depict that. And you're, again, in this case, unless you advertised a discount, you should be a non-discounted billing here. You do not have to negotiate. I can't tell you the amount of times that I basically wrote on their negotiation response, we will not negotiate this. Please send it back to insurance for reimbursement. Last week, I renegotiated, or they came to me with three of them, and I've been paid this week on two of them that I already, with no reduction in the amount of reimbursement. It was exactly what we had anticipated our billing to be. It was an 80% or 100% group. So you do not have to negotiate with them. And when they tell you, well, we can pay you in 15 days, if you do say yes, you might look at that because it says 15 calendar days often, and that's three weeks. So they really have the fear tactics. They have no power, to be honest with you. So if they do come up with a rate and you want to negotiate it, I mean, you have every right to do it, but I have found that 0% of the time has it ever stopped my claims from being processed. And on top of that, I've actually accepted it in the past, thinking that it would be fast and got denied within three days. So they have no power and I just definitely would not negotiate your claims with these groups. Okay, estimation of benefits. One thing I really want to say about this, this is what at the end of the process, you're going to see either a check with an estimation of benefits or a denial with an estimation of benefits. Rarely is there going to be kind of an in between with that. What you want to understand is that you receive the estimation of benefits and the patient receives the estimation of benefits. So if you have a one number written on their contract and you're billing another number entirely, you're going to probably get in trouble with them and then your insurance company or their insurance company, because that's inappropriate. They should be able to pull their contract out of whatever their file that they have at home and look at the number that you billed and it should be right there on their page showing what it was. Now the insurance company is going to pay what they're going to pay. And you're going to be able to work with them on collecting what's left over of that. But understand that the EOB will be spelled out specifically as to what was billed, what was paid, what the patient responsibility is, what the write-off should be. And often if there's a contract, you want to make sure that it fulfills your contractual obligations as well. No one likes to write off money, but in certain cases it's necessary. If your contract says that you have a write-off, you should be writing off what it says you're writing off. If you've attempted to collect monies from a patient after the fact, and you've shown that you have diligently gone through and they're just not writing or they're not paying it, document, document, document, you can then write off what's left over or negotiate or whatever is necessary on that. But you don't want to tell a patient that you're going to write off an amount before you ever billed the product. You want to make sure that any write-offs or any negotiations with the patient happen after the insurance company has paid their part and you work directly with the patient on their portion of it to collect as much as you possibly can and if you need to write it off, make sure you document it. Because I've come across two things when it comes to my P&Ls at the end of the year, we need to know how much we wrote off on the year. And if it starts to look like a really high number, we have to start asking ourselves about the contracts that we have. Is it too much that we're having to write off? Is it really cutting into our cashflow? The other thing is if you're a commission-based company or you have any kind of incentives that you're giving your employees on quarterly or monthly sort of sales contracts, and you found out 90 days down the road that you just wrote off a chunk of insurance, that person was paid a commission based upon the full amount. You have to determine if your contracts with your employers include going back and structuring or changing that to reflect the actual amount paid versus the sales amount that they were able to do on that day. So that's between you and your practitioners, but it's something to definitely consider and think about. Okay, so we have some balanced billing laws in different states. I know California, Illinois, listed in the lighter blue states here, and there are substantial laws regulating a practice's ability to balance bill. So make sure you are aware of your states. And also it could be carrier to carrier to carrier as you go along too. So again, read in your contracts, know if you are allowed to do any kind of balanced billing. All right, compliance and oversight. So there are groups out there that are gonna watch what you're doing, especially if you work with federal type programs. They're very specific to making sure everything's being done correctly for the patient and for the insurance company. So if you do any kind of Medicare billing or Medicaid billing, I know we've been audited twice on Medi-Cal. It's something that I would expect we're gonna audit again. It just happens that way. So be prepared to have that happen. But if you have a strong compliance program in place, it's not mandated right now for hearing healthcare officers or hearing offices to have it. But I have been very thankful that we had a process in place on every one of our audits because we were able to show this is our process. And in one of the audits, they could see that one of the things we had in the process, we were doing incorrectly, but we were able to correct it. And that made it so, again, we had maybe a slap on the wrist if that, and we're able to move on and learn from that going forward. So we do have a template, like as I mentioned earlier, and it's been said, it's coming out in a bit, that has a compliance program to look at. It's not a cut and paste type idea, but it is something that you should consider going forward if you work with insurance to have this type of thing, a compliance program going on. The Office of the Inspector General has done numerous different, I don't wanna say sting operations, but they have numerous different operations that have been out there that have found people that have had salespeople close these deals and whether or not there was medical necessity or not, billing for more than what was going on. You can find these in the news left and right. In this case, they were selling hearing aids even with wax buildup inside of the person's ears. So there was no sending off for referral. There was sell, sell, sell, sell, sell. And because they were working with federal insurances, this came under the Office of the Inspector General to work with that. I know our states even have some specific offices that work at the state level for them. Fraud, waste, and abuse, this is something that if you haven't heard of this little three-word phrase, you should really kinda get it to memory and be concerned about it unless you know everything you can know. Because this is something that should end up in your compliance program. It's something that is continually looked at at the medical, hospitals are looking at this. Anybody that does insurance billing, you should be aware of fraud, waste, and abuse. There is not enough time to go over all three of those things in this webinar. But if you do go on, you can go on to the different websites through Medicare. There's different links to be able to find to do the training. I know there's a couple third-party groups that actually require that you have the, you have fraud, waste, and abuse training. And you can even put it in your own compliance program that your staff has fraud, waste, and abuse training as well. But I'm going to go ahead and leave you with that one. So as you go throughout the rest of your insurance getting started, then that's something you should work with. So we're going to move on to our questions. Great, thank you so much, Joe. We're so excited that over 200 of our colleagues and followers have joined us today on the webinar. And as you mentioned, we do have time for questions and answers. So as a friendly reminder to our viewers and audience, if you have a question for Joe, please go ahead and enter it into the question box on your webinar dashboard. So Joe, let's get right into it. We've covered a lot of information today. We've got some good questions percolating. So our first one here is from Bruce. And Bruce says, I was told that a hearing instrument specialist cannot bill for hearing tests. How do I know what I can and cannot bill for? I mean, that's a great question. The basic answer is if it's in your scope of practice, it listed in your state's practice act under your license, you can bill for anything under your scope of practice. The issue that happens is that insurance companies don't pay you because they don't have it in their fee schedule to pay your taxonomy code that way. So you can bill all you want. And some carriers might have a policy that has that in there. But if you do find that you're in the process of billing for specific services, you gotta make sure you're billing also the people that the insurance companies don't cover as well. Great, thank you. We've got a question here from Gregory. And Gregory wants to know what is balanced billing? So balanced billing is if you have a contract with an insurance company that states that they pay a certain amount and your product costs more than that amount. Once the insurance, the estimation of benefits comes in and it says that, oh, we paid our amount. Let's just say you had a $5,000 set of hearing aids and they only pay three. Well, on the estimation of benefits, it's gonna say they paid three and that you can't balance bill the patient any further. It's usually specific to a contract. If you can actually get in a lot of trouble at that point of balanced billing the patient without permission. There is some different, if you look further into coding, there's some codes that can be used and there's a few different things you work with a patient. Some insurance companies accept S codes at the beginning of it, but I won't get too far down to that. But yeah, it's billing above and beyond what the contract states. Thanks Joe. And so to that slightly deeper, can you tell us what no protection means regarding balanced billing laws? That means that there's no protections for the patients, from what I understand, in those states. The state doesn't have a mandate for balanced billing. So the insurance companies actually can do more specific to contract versus, I think that's the least strict of the ones that can be done. Great. Now we've got a question here from Jenna and she asks, some of the patients we bill for are denied, required, excuse me, are denied or required, a denial from Medicare while others don't. How do we know which one has the requirement? Can you repeat the question? I'm sorry, I got kind of glitchy there. Some of the patients we bill for are denied from Medicare while others don't. How do we know which has the requirement for the plan? So what I've actually learned to do is I send out a similar package to a lot of insurances. And what I include, because sometimes you never know, you never know who's gonna get denied as a Medicare, bill Medicare first denial and who's not. So there is actually a Medicare workbook or form that we found the specific page that states that hearing aids are a non-covered service by Medicare. So we just include that on all of our billings so that it usually covers that sort of an issue. You'll learn the carriers that do that often. We've just made it be kind of a basic process where we include that letter on all of our stuff. Okay, got it. Thank you. We've got a question here from Carol. When you submit hearing aid invoices to insurance companies, do you black out the account numbers for security purposes? She's concerned about random people having access to the account. I'm not sure of the risk really involved with that. I would say one thing in your contracts, I keep coming back to that. I know with the contracts that we do provide our invoices that we're required to, they will actually deny it because it's marked. So you wanna make sure you read your contract. I don't believe that they're gonna be able to do anything with your account numbers, like an order hearing aids under you or anything along those lines. And most of the major carriers of insurances won't let the insurance company call up and say, hey, what are the pricing of this group? It's pretty much a no-no in that case. So I really wouldn't fear having your account numbers. Now, I'm sure you don't have credit card numbers or anything like that on there. I would definitely black something like that or make sure that the company is not allowing that, but I wouldn't be concerned about your account numbers being seen by the insurance companies. Okay, got it. Now, Susan wants to know, she's a practice owner, and she wants to know, she never knows if she's supposed to use her personal NPI or her practice NPI, which is correct. So that's, actually, if you set up your billing in some of these online stuff like CycleNet or I believe some of the other ones have, automatically placing the right NPI in the right spot. The answer is both. On usually the line item you're gonna do on a HCFA, you're gonna see the rendering provider NPI, I believe is the exact name for it, and that's gonna be at the very end of the line. But down on the bottom left two boxes of the HCFA, that's gonna be your office or the organization, I should say, NPI. So the answer is you should have both on the form, but the organization one is definitely required versus the personal one. Different, again, follow your contracts. Different insurance companies may vary a little bit. It's good to have them just both on there because you don't wanna get denied because you didn't have it on there. Okay, thank you. Omar wants to know, we advertise free hearing screening, but not hearing tests. Are you suggesting that it's illegal? It's not an illegal thing. The issue is not necessarily, and again, I'm not an attorney to state that. If you advertise free hearing screenings, I know in my specific example, the state laws state what we can advertise and what we do say. If you say you're going to do a hearing test, determine that it's misleading as a diagnostic test, so you have to clarify that it's not diagnostic. So a hearing screening is never, most screenings are never considered diagnosis of anything. So if you're saying hearing screening, but then if you turn around and you actually are performing an actual hearing test, you have to be careful about who you're charging and who you're billing. But I don't believe there's any, I don't know unless your state laws specifically say you cannot put hearing screening out either, that there's something illegal there. But just be aware if you're putting free hearing tests of your state laws, and also if you then are charging people, that's illegal. So if you say free anything and then you charge somebody, you'd be mad if you went down to Best Buy and they said free computers, you walked in and you didn't get one, right? That's the same kind of idea. You wanna make sure you're not charging people when you've told them that it's free. Good, thank you, that's really helpful. Chelsea wants to know, she's a hearing aid specialist. The insurance claim form asks for a diagnosis code, yet her state laws prohibit her from diagnosing a hearing loss. How can she submit a claim without a diagnosis code? That's a great question. And one thing that we should all get into our mind is that if you're not a diagnostician, you're not an audiologist or you're not an EMT or an MD, the best you can do is what your training has led your opinion to be. So if it's in your opinion, a mixed loss, or it's in your opinion, a conductive loss, well, if you've documented that in the patient file, that you, in your opinion, or this is consistent with those things, you can use that diagnosis code. You're not giving the patient a diagnosis. You're not saying you have this without saying it's my opinion you have this. So on the form, you're just being as clear as you can based upon your training and your personal opinion. Thank you, Joe. Heather wants to know, when running a special 50% off MSRP, do you have to build an insurance with the actual 50% off price? If that patient came in off of a program that you were throwing that said 50% off the MSRP, if you then bill the MSRP to the insurance patient and you give a private pay patient with no insurance 50% off, you could be in big trouble with that insurance company if they do audit you and see that you're upcharging them, basically. So what is often happening is, at least in my area and with colleagues I work with, is people aren't really advertising that exact type of thing anymore that are taking insurance because you're gonna have people come off the street that have a random policy that would cover 80% of the hearing aids, and then you're gonna get 80% of the 50% that you just had to bill. So you have to be careful of that. So I would definitely say either don't advertise that at all or you can say some restrictions apply, but if you're even more specific and say this does not apply to insurance carriers, maybe that's the way around it. So it just takes a lot more real estate on your advertising to put all of the no's versus not doing that in the first place. Mm-hmm, makes sense. Can you share, Joe, how do you submit your Medicare letter along with your claim submissions if you're submitting electronically? That's a great question. I know there's often some protocols as to how you're gonna submit electronically. Like sometimes, I know in California, we do with our Medicaid programs, we actually have to fax one thing and scan another. So if you're fully electronic and you have a PDF copy of that letter already in your files and you're able to create a package and send it over and your insurance company accepts that, then that's a great way to do it. Other than that, if you find yourself with just a stack of paper trying to justify the claim you're doing, put the paper in the mail and mail it to them. I mean, I know we wanna be electronic, but if you're gonna get denied, and I've had it happen recently where I've gotten denied because they didn't have a piece of paper because of the fax machine issue. It said we sent the fax and the other side never received it. We had to turn around and we had tens of thousands of dollars in billings that were denied because they were missing the invoice that was required by that contract. We had to turn around and mail those in and wait for reimbursement a second time around. So if you have no way of attaching files to your electronic billing, then you wanna look at mailing them in. Gotcha, so can participating providers request that patients submit the billing themselves? And as a follow-up, how well do non-participating providers get reimbursed for goods and services? So this is kind of two parts to that. So the first part of it, I believe the answer is yes, you can have a patient on their own behalf submit a claim. I know of many colleagues that have done it. I believe you have to be careful if you're picking and choosing. I think if you're a participating provider, especially if you're contracted, I don't think you can turn around and then have people billing their own thing. I believe you should be the one that's doing it. But if you are a non-participating provider, I know several colleagues that don't participate at all, but they give the patient the information to send to their insurance company. One issue that happens is liability. So if you're helping the patient fill out all their stuff and send it in, you can become liable for the fact that you gave them that information to work with. So if they wanna call their insurance company and ask if they can submit their own claims and they can work directly with their insurance company, it's always great to have a billing specialist in your office. And I can't clarify this enough because that person can maybe specify a few more of these things. Someone who's a little more advanced in knowing what's going on with insurances as this goes along. So the second part of that question, sorry, what was the second half of that question? I think that was the first half. The second part was how well do non-participating providers get reimbursed for goods and services? That's gonna depend on every single carrier. I know in my specific area of the world here, we have groups that pay 100%. We have groups that pay 80%. We have groups that there's groups that pay $1,000. Our fee schedule is set up so that we have our price. We're able to offer a discount if people come in and they pay cash or they have a prompt pay discount, we should say. So when I bill the non-discounted price to an 80% company, sometimes they pay 80% of that. Sometimes they pay 100, if it's 100%. Sometimes they pay 50%. I'm sorry, they pay 80% of 50%. So it's almost impossible to know unless you've just worked with the insurance company and numerous times and started to know that they're gonna tell you that they're gonna pay 100% and they're gonna pay 100% of half of what you bill. And then sometimes they'll tell you again, you can't balance bill. It just really depends on what comes out of the insurance company. So you wanna poise yourself with a non-discounted price that matches, you have to watch your total units across. All you're doing, this is getting a little more specific I think than we need, but you wanna have it down to know exactly what your pricing is so that you are billing the correct amounts to the insurance company. You're not over-billing them. You're not changing your billing. You're following the processes you have in your office so that you can write off or take the differences the insurance companies are gonna give you. Thanks Joe. So we're approaching the top of the hour. So I'm gonna ask one more question. And this one comes from Luann. Do you have to obtain a copy of the patient's Medicare card even though our services are an exclusion of benefits? I don't believe that most of the companies are gonna ask you to provide Medicare card copy, especially if the benefits are excluded. The issue that comes up is whether we collect even the cards in the office. If people come up and they're used to just throwing them. I've had numerous people hand me their insurance cards, both their supplement and their Medicare. And we don't even take a copy of their Medicare card because there's zero billing that we do with Medicare. But your office and your contracts might be different. There might be a company that says, okay, per our contract you have to provide the Medicare card. And if that's the case, you wanna make sure that your compliance program is there and you're A, collecting it and B, you're providing security in your office for HIPAA so that no one can access those cards and that data in the future. But I definitely would follow contracts. But what I've known is that if there's no Medicare coverage and it's in fact, cause there is no real Medicare coverage for hearing aids then you shouldn't have to provide the Medicare card. Joe, thank you so much. We always have so many questions and never enough time but we are at the end of our time together. So I wanna say thank you so much for a wonderful presentation. And a reminder to our members that you can get the 70 page guide to third-party participation in the IHS tour online for a deeper look into managed care cause I know we're covering the basics today. We welcome you to join IHS if you're not already a member and take advantage of this incredible benefit. Also, do keep an eye out for the compliance plan template in early 2020. It's gonna be produced by the IHS Managed Care and Compliance Committee of which Joe is a part of and available exclusively to IHS members. Joe, thank you once again for your time today and sharing all this information on the IHS webinar, the basics of managed care, what you need to know. If you'd like to get in touch with the IHS Managed Care and Compliance Committee with additional questions, please visit www.bit.ly IHS Managed Care Committee. Fill out the form and the committee will email you back. For more information about receiving a continuing education credit for this webinar through IHS, visit the IHS website at ihsinfo.org. Click on the webinar banner or find more information on the webinar tab on the navigation menu. Please do keep an eye out for the survey that you will receive tomorrow via email. We ask that you take a few moments to answer some brief questions about the quality of today's presentation. Once again, thank you all for being with us today and thank you, Joe, and we'll catch you all at the next IHS webinar. Thanks and have a great afternoon.

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