We are presenting a three-part webinar series to educate health centers about commercial insurance billing. Billing student’s private insurance generates incremental revenue for your health center, so you can maintain or add to the level of services provided to your students. Part one in our series is the “Insurance Billing Round-Table” below. In this pre-recorded session, you will learn more about how insurance billing works as several college and university health center representatives participate in a lively Q&A session.
This webinar will help you learn:
- What commercial billing includes.
- What timeline your center is looking at for implementation.
- If you have to start charging for co-pays.
- What happens to student health fees.
- And much more.
The second part of our series, “Myths and Misconceptions”, is a live session this Thursday, March 15 at 3:00pm EST. This webinar will dispel the rumors and give you accurate information about commercial insurance billing. To participate in this live webinar, please click here. If you cannot attend, don’t worry! A recording of this webinar will be posted here soon.
Marsha: Jim, I just had a question- as a small university and a small, very small staff what do- what does our university need to do to start a billing services through you?
Jim: An excellent question- what I hear a very frequently. A small school with limited staff really is resource challenged to start their own billing service for insurance.
I don’t want to scare you but there are a number of steps that are required including
working with the insurance companies, getting credentialed, contracting and then of course the daily process.
That’s when I recommend for smaller school with limited staff, which is already stretched in their duties, to look to a service organization- a service agency like our billing services at Nuesoft that can help set up the proper tools for implementation, proper start-up to be successful- ensure that you will be successful.
And our goal is to step-by-step take care of the daily requirements. Take the hassles off your back- everything from setting up the program to working with denials. And any other problems that come up once the insurance is billed.
Marsha: And then my last question would be the timeline then. Say we did want to start trying to maybe bill for fall of 2012. Is that even possible? Do you need a full year? What kind of a timeline?
Jim: The timeline for starting a billing program at a university through the Nuesoft program is typically a four to six month process.
We meet with you once an agreement is signed. We do a project management timeline- working backwards from your date of go live with the billing and typically to set up the program is only a two or three week process.
However, to make sure you get in-network credentialing and manage contracts to
get the best reimbursement for your services- it could be a five to six month program
but we definitely could set up your billing program for the fall of 2012 if you sign an agreement early in 2012.
Eileen: I would suggest starting that a little bit earlier because the credentialing process, Jim, you know can take as you said 3 to 5 months. And plus working with that
system to get the training done and whatnot.
Summer is much slower- I don’t know if you’re open in the summer? Yeah and they’re not even open in the summer. So you know, if they’re going to be ready to go in the fall then I would start now.
Molly: Jim, this is Molly. And I work at Dennison University which is a small 2,000 student community. I have a couple of questions. The first is that when you talked about Nuesoft doing an analysis of the utilization and that really needs to be done before obviously any contracts are signed, correct?
Jim: That is correct. We help determine what the potential is for your school to generate incremental revenue and we go through that analysis prior to any serious consideration of an agreement.
Molly: And how long does it take to do that analysis?
Jim: What we do is submit a form to you with a series of questions and then based on your response and timeliness of your response it takes us only 48 hours to put it through our computer analysis where we compare your data to our other clients performance and based on that algorithm we generate a very reliable projection for you.
And it’s typically a bit conservative but it’s something you can depend on with your expectations for your health center.
Molly: Does that analysis- is that based on what we have been charging for services and transactions?
Jim: No. We assume that you have not been charging for any of your services so we do not base our projection on anything you might have been charging to date. What we do is look at regional fees in you area and based on those usual and customary fees, we assume that your new fee schedule, once we set up your billing program, will be based on
the fee structure that is established.
Then based on the frequency of the service being generated on your historical performance at your or utilization at your health center we then generate that projection for you.
Molly: OK. And so in essence right now at least for most- I think almost all of us- we’re a non-profit, you know. We’re not out to make a profit but when we convert over to an outside company doing the billing system- in essence, we’re becoming a profit making institution. Is that not correct?
Jim: A very interesting question. Technically your status does not change. You remain a non-profit organization within your institution. However, you do generate revenue and that revenue is incremental resources for your budget.
That doesn’t mean that you’re non-profit status changes. It simply means now you have more resources that were generated. But technically and legally your non-profit status remains the same.
Molly: Okay so my question is, I mean is it fair to do that and to also have a student health fee?
Jim: Yes, this is a question that comes up with every school I talk to that has a health fee. And it does mean that you do have to review your policy and communicate to your
students and the parents the change in that policy which basically is that the health fee now is for your infrastructure to support that. Their access to your health center for health education, for special programs that cannot be billed including supporting mental health as applicable and appropriate for your particular school.
However, the charges that you will be billing the insurance company are for services actually provided which are separate from your health fee.
Molly: Another question I had- in terms of the credentialing- that doesn’t equate or equal a school having to be accredited. I mean a health center clinic having to be accredited does it?
Jim: No this is a good point to clarify. Accreditation has nothing to do with your providers being credentialed by each insurance company. In other words the credentialing
process is establishing that each provider has a proper background training, education, and experienc e to provide the services that will be submitted.
And each insurance company has a different process which our staff handles that credentialing requirement for you and all your providers.
Molly: A lot of our students at this age like confidential billing because they don’t want mom or dad to get an EOB or any of that kind of stuff. Do you personalize the system so that things like that- confidential billing can be accomplished?
Jim: An excellent, excellent point. This is where our experience in college health- that of Nuesoft for almost twenty years is really critically important. We understand the importance of the question you just asked and that is if it’s a test for pregnancy or STD- that the student very well might not want that EOB to go to the parent’s home and the criticality of the confidential nature of their visit.
And we do not want them not to come to your health center because they’re worried about that. So what we do is set up a policy with you and the implementation- and our
account manager works with you and makes recommendations and gives you options
to allow you to bill the student directly at the time of their visit privately and not submit
that to insurance.
And as a company where we get a percentage of the collections we have no problem with that. We understand that importance of dealing with that student on that basis.
Eileen: When you go into your ticket you can basically do the self pay rate. For those visits that the student does not want going into their insurance. Or you can do the visits billed by the insurance. You and the student get to decide- creating the tickets so you can manually change that so that it would be billed just to the student and then not go through the insurance system. You can work around it. OK.
Molly: We actually have people who stay with us, you know, in bed for 6 hours, 12 hours, 24 hours or whatever and so the whole- you know, insurance companies don’t pay for observation care unless you’re in a hospital. So how would you work that kind of thing because a lot of parents have to pay for that out of pocket?
Or if they take this extra Denison health insurance that we offer- we’ve crafted it so that it will pay for that.
Jim: An interesting situation. A couple of comments come to mind. One is our goal is to
minimize and eliminate if possible any charges to the parents or students which is a benefit of a billing service for your customers so to speak- the students and the parents.
This is also the benefit of working with the billing service like the Nuesoft billing agency. We have experts on staff, coding experts that when a situation like that comes
up- we consult with them and if they don’t have the answer ready, they know where to go to get the best answer and advise you and your staff how to do the coding.
In this case we feel that there would be a couple possibilities and this depends on each insurance company and the patient’s plan. If the insurance company denies coverage
then we might have to go to that insurance company and ask for a waiver so that they would cover for you. Another insurance company might cover it but need a referral first
and therefore we would recommend to your staff or our staff- go and get that referral and permission approval prior to the overnight observation.
So there are some complications here that have to be determined by the situation at the time. The benefit to you as you have our experts staff working side by side with you to help you determine the best procedure to make sure you do get reimbursed.
Ester: Hi. I’m Ester from College of Wooster. We have about two thousand students. We are one of the overnight facilities and also we charge for very little at this point. Was wondering what your minimal reimbursement was or your projected to be significant is to implement this program?
Jim: That’s an excellent question and that is an important consideration for us because to establish a billing program on your campus, to do the implementation, to do the ongoing work, we do not charge you a penny- we get no reimbursement. We never give you an invoice.
So we want to make sure that in the long term it is worth our while to work with you monetarily, financially. Therefore we do this projection and have a stakeholders interest in making sure it’s accurate because that will determine what our potential return is as well as how much incremental revenue you’ll generate. Typically, the minimum that makes it worth our while to get involved in setting up a program and working on a
ongoing basis is about $50,000 to $75,000 annually.
Randi: OK. So my question is- we are like Oberlin in the fact that we let them waive the insurance if they have their own. But we have kids from New York, we have Massachusetts State Insurance, we have kids from California, we have kids from Florida- all with different insurance companies, different providers, different everything.
So do you get us credentialed for everybody or is it just some people?
Jim: A good point. Your situation is not totally unique. We have other private schools that draw students from all the states and a number of international students.
So we have had to face this challenge. The good news is that Nuesoft has, in the medical side, clients in all 50 states where we do insurance submission for them. And that means we develop relationships with insurance companies around the country in every state.
This gives us sort of an advantage, an insiders positions so to speak, to working with these insurance companies so our goal is to get you credentialed with as many as possible.
And a practical side- our actual goal is to get you at least 80% of all your visits the first year in-network where your providers are credentialed and then each year we add to that
Keeping in mind we still can bill when you’re not in-network but the reimbursement is less. So our goal and our motivation because we get a percentage of collections is to in fact that you credentialed and in-network with as many insurance plans as possible.
Marsha: This is Marsha Tilden from Ohio Wesleyan University- one more question. What would you require from our staff? I guess to do we need to hire an extra staff person to deal with getting all the codes done correctly or what do you need from us is what I’m asking.
Jim: Basically there are two things you have to do. One is collect the insurance information which by the way because you’re a Nuesoft customers, you could do through our Nuesoft student portal and have the students input that insurance information into the system. And number two is to actually do the coding of the service and the diagnosis when the patient is in your health center. And we give you coding classes, we train you to do that coding, we have certified coders that help set that up for you.
And it is your job though, when the visit takes place to do the actual coding. You do not have to and none of our clients have ever so far had to hire an extra person but we do help evaluate your staff’s assignments in advance in case you do have to look at adding a part-time person.
Our goal though is for you never have to do that.
Molly: Jim this is Molly with Denison again. Did you say what you do then with insurance companies that you’re not connected with that don’t pay?
Eileen: If you’re got private insurance what ends up happening is- at least how we’ve set it up and many schools have set it up is there’s no co-pay. There’s no deductible charges in the health center.
So if John Smith goes towards- has this charge that goes towards his deductible and it’s $150 cause the insurance billing prices that- we then go back and we re-do the bill to the self pay rate for that person so they are not going to pay the $150 for the HEPA shot. They’ll pay $42 because it doesn’t cover because they’re a high deductible plan currently.
Once healthcare reform goes into effect starting July, 2012 then all of our bread and butter, which is what we’ve been doing, will be covered by those health insurance companies at that rate.
So there is no out-of-pocket cost to that student.
Molly: Does it work with students who are on Medicaid?
Eileen: If you become a Medicaid provider then Medicaid covers. Medicaid reimburses at a very low rate. Some schools opt not to be Medicaid providers. Others opt to be Medicaid providers. That’s a personal choice that you will need to look into to find out, you know, what you want to do and how you want to handle that.
Currently, we have decided not be a Medicaid provider because of all the requirements that are required and also the low re-imbursement rate.
We basically for anything that’s Wellcare that’s covered, we send them to their Medicaid provider. For anything that’s illness related, we do the self pay rate, which soon Medicaid is going to charging co-pays.
And our average co-pay or our average charge for the self pay rate is $15. which is going to be less or about equal to the Medicaid co-pay. So that’s how we are handling Medicaid.
We are handling the student health insurance and the employee health insurance vendors
basically as a work-around. We are not going to be billing through the Nuesoft system.
We’re working with them to work around it using the Nuesoft system data that we already use. Like for the IOUs that go to the bercer’s account. We’re going to make something for the student health insurance to batch bill. And for the employee health insurance to batch bill because we are not going to be charging co-pays, deductibles, anything for those plans either.
Marilyn: Did Eileen say we don’t charge for co-pays?
Jim: This is another good question and a very important question. It’s a case where every school asks about this and there are legal requirements when it comes to co-pays. The good news is this is where you also benefit from working with our expert staff because they advise you on your options.
Co-pays are legally required by each insurance company for you to collect. However, because you do not want a co-pay to be a barrier for a student to have access to your health center, there are ways to get around actually collecting the co-pay.
If you have a health fee now, the insurance companies at our request, on your behalf, will waive the requirement and assign the health fee and make that a prepaid co-pay and therefore you’d never have to charge a co-pay for any service.
There is also other good news now with the affordable care act. Preventive services as of 2010 are now required to be provided without any cost sharing by the patient. Which means any preventive service to you offer or provide for your students, you do not have to charge that co-pay and doesn’t apply.
And in 2013 all women’s healthcare preventive services for anything like mammograms or screening or obesity screening- again there is no cost sharing where no cost co-pay will be required.
So basically during that implementation process- that’s a time when our staff reviews the requirements and gives you options and lets you know what policies you come up with that you feel are in the best interest for your school.