Is Your Agency Exploring Contracting with Commercial Insurance Plans? Here are a Few Items that should be on Your Punch List.
Most Community Behavioral Health Centers (CBCs) have been focused on the administrative and clinical implementation of behavioral health carve services for their Community Medicaid Managed Care Plan (MCP) clients. At the same time, many agencies are beginning to see an increase in requests for clinical services from potential clients having commercial insurance.
Commercial insurance is a whole different ballgame regarding covered services, billing requirements and eligible providers. Agencies that assume that a commercial insurance plan “operates” the same way as a Medicaid plan will be very disappointed as well as thin on revenue generation.
If your Agency hasn’t contracted with commercial insurance plans to date, you will want to make sure these items are on your “due diligence” punch list of items to consider:
Carefully research and review commercial insurance plans’ clinical and administrative requirements on its website
Part of the due diligence process is explore all clinical and administrative aspects of a commercial insurance payer. Your organization should review such areas as clinical authorization requirements, clinician participation criteria and reimbursement of your services. Your organization will want to conduct a cost/benefit analysis to make sure that the “squeeze is worth the juice” in contracting with commercial payers.
Understand what kind of contract your organization will need in order to have its clinical services covered under commercial plans
Unlike Medicaid, commercial insurance plans have different kinds of contracts to pay for a covered members’ clinical services. It has one type of contract (Group) that will cover routine outpatient services (assessment, individual therapy, physician visits). Many payers have a different agreement (Facility/Institutional) that covers higher levels of care such as SUD IOP, SUD PHP and Residential Treatment.
Does your organization have the organizational administrative infrastructure to manage commercial contracts?
Your organization will need to comply with the various commercial insurance requirements around billing, authorization and client financial responsibility (deductibles/co-insurance). Does your organization have the “bandwidth” to meet these various administrative and clinical requirements such as verifying eligibility and benefit levels, tracking clinical authorizations, billing the right codes (revenue and/or CPT codes) on the correct billing form (UB04)?
G&M Consulting has over twenty eight (28) years experience in credentialing and contracting in the commercial insurance world. In addition, we assist organizations in implementing administrative systems that will help manage the various commercial insurance requirements.
We want to make sure your organization has the insight necessary to thrive in our brave new managed care world!
Please visit our website at https://gmbhconsulting.net/ or feel free to email me at firstname.lastname@example.org with any questions that you and/or your staff may have regarding the commercial insurance credentialing and contracting process.
And as always, please let us know how we can be of service to your organization!