Problem:
Each third-party payer may have different credential or licensing requirements for the clinician who is providing services.
Solution:
Make sure you know what each third-party payer’s requirements are for credentials and licensing for different services. Assign clients appropriately to maximize reimbursement.
Featured Stories
Liberty Center Connections, Inc. in Wooster, Ohio decreased the claim error rate from 33% to 16% and increased insurance reimbursements from 10% to 17% of total charges. Included in their efforts to follow contract stipulations, they created a list of insurance providers and the credentials required for reimbursement for services provided. They also registered clinicians with CAQH (the Council for Affordable Quality Healthcare), a nonprofit alliance of health plans that handles the credentialing application process for providers and the health plans with which they want to be affiliated).
Solutions Behavioral Healthcare in Medina, Ohio reduced the denial rate from 6.5% to 1.7% by scheduling clients with third-party insurance with an independently licensed clinician. They analyzed reasons for claims denial and found that 10 out of the 39 rejections in their baseline analysis resulted from the client being scheduled with non-independently licensed staff.
District II Alcohol & Drug Program in Sidney, Montana negotiated to have the area’s largest employer’s insurance program accept Licensed Addiction Counselors (LAC’s) instead of PhD- level providers, on the grounds that there are not enough PhD level providers available in the area to serve their insured members. They estimate that this will increase their revenue by $5,250/year.
Lessons Learned
- Create a list of third-party payers and their requirements.
- Negotiate with the third-party payer for exceptions or special circumstances.
- Encourage staff to continue their education to get the appropriate license.
Tracking Measures
| Cycle Measure | Data Collection Form |
|---|---|
| Denial rate = Total Number of Denied Claims/Total Number of Claims Submitted | None |
| $ of revenue from third-party payers | Revenue by Payer Worksheet |
ActionSteps
—
Related Information
- For the credentialing application process: CAQH (the Council for Affordable Quality Healthcare)
More Stories
Quest Recovery & Prevention Services in Canton, Ohio increased revenue by $18,900. They improved the intake process to identify third-party clients earlier in the process, which allowed them to complete pre-certifications and match assessment and potential treatment with the correctly-licensed clinician.