Rumors that cause issues

Often I'm asked questions about billing/credentialing issues with the statement "another biller" or "another provider told me"...

There is a lot of misunderstandings or misguided people in this business field. I admit, in the past I have been told wrong information and shared it as well, but only to later make a statement to say what is really correct for particular circumstances with evidence to prove my point. Whenever I share info now, I make sure I've seen evidence or read the legal document before I confirm it's true. And the beauty of this field is most of results are quite black and white.

Here are some of those misguided rumors or questions I'm often told/asked:

Commercial insurance companies can not be billed for more than 1 evaluation per year.

Not true. Most can be billed at least 2 evaluation codes per year. I always recommend therapists to evaluate based on the billing schedule of Medicare or Medicaid. I also recommend no matter if the patient is private pay or insurance filed, follow rules/regulations of Medicare/Medicaid in case the patient were to change to filing insurance later. Therefore there's not a rush to make sure test scores/POCs/documentation is in place for authorizations with new insurance filings.

Commercial insurance companies use the same modifiers you would use with Medicare/Medicaid claims.

Yes and no. Alpha codes (ex: GN, HA, GT) are federal modifier codes. Certain insurance companies prefer you do tack these codes on, but they are used for Federal insurance programs (Medicare, Medicaid, and Tricare). United Healthcare and Humana do like to see these codes added to certain claims, however they do not want HA added usually. By the way, HA means pediatric if you're curious. And this is always subject to change.

Medicaid gives companies provider numbers.

False. To enroll in most Medicaid programs, you enroll the provider and attach the information about the company they are working under in the application.

Can a CFY work see Medicaid patients?

Yes. Medicaid enrolls a provider based on their state license. I have had several of these applications approved for the past few years for Georgia, however other states might have different laws. CMOs can credential CFYs as well (last time I credentialed a provider).

Not updating CAQH/Availity will cancel my contract with insurance companies I'm contracted with.

Yes and no. It is important to keep your information updated, some contracts do require it. However insurance companies are require to notify you in advance (whether via newsletter, email or letter) if their credentialing requirements have changed. It's also simply good practice to keep your information updated for claims that are filed out of network, member searches looking for provider, contact information for other providers needing to refer patients, and of course for contracted insurance companies to reach you.

Often marketing companies like to scare providers, playing on their fears that they have missed a notification or are out of compliance, therefore needing their services. Make sure you can comprehend those are scare tactics, and realize the difference when it's a company actually being helpful.