Implementing Medical Billing

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Q. When enrolling with insurance carriers as a medical provider, should I become affiliated, or contracted?

A. The answer to this question is not simple, but we can break it down into two basic factors. How you currently bill that insurance, and patient demographics. The easy answer is IF you are a contracted provider in dental, you should probably contract in medical. This means you are an in-network provider and have agreed to the fee schedule associated. If you have already agreed to this in dental, there is no harm in agreeing to the contracted rate in medical. The other option is to be affiliated, meaning you bill as an out-of-network provider and will submit “usual and customary reimbursement” rates. Insurance will either agree and pay the allowed rate, or send an offer based on their maximum allowances. The second answer to the medical contracting question, is purely driven by patient demographics. Some insurances such as MediCare or MediCaid, do not allow out of network billing. If 30% of more of your patient database assisted healthcare, or a similar insurance (HMO, EPO, State Funded) that does not allow out-of-network billing well, you are eliminating the possibility of medical insurances covering the fees. JA

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Q. How long does it take to implement medical billing into my office, and do I need to hire another staff member to handle the process?

A. The initial start-up accreditation/contracting phase can take weeks, or up to 6 months depending on the insurance and level of enrollment. Government contracts tend to take the longest, 4-6 months on average, to become contracted providers. Once you are properly enrolled with insurance, documentation and dictation will determine how likely the claim will get paid, or flagged for review.

There is a bit of a learning curve here as most general dentists are not accustomed to writing clinical exam or surgical notes for medical necessity. Any denials, appeals or reworking of notes delay payments. Having the doctor involved, or having a specialist assigned to this role increases the success rate immensely. Hiring a medical billing specialist is recommended, but not required. Medical billing is not an easy task for one person to handle, but if the office takes a team approach it can easily be implemented without too much burden. Starting with a focus on a single procedure type and then expanding into other, or more complicated procedures seems to work best for most offices. If your office is adding a new procedure (such as Sleep Apnea Treatment) into the office and assigns a specialist to handle these cases, then we recommend this person also handle the majority of the billing. JA

• This reply was modified 5 years, 8 months ago by admin.

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