From time to time, G&M Consulting receives questions from the behavioral health field asking guidance regarding various commercial insurance payers.  Here is a question that was received recently that we felt would be beneficial to the community at large:

Question: 

My practice just signed a Group Agreement with a large commercial payer.  How do I “operationalize” that agreement so that my staff understand all the various rules that have to be followed both clinically and administratively so that our practice gets paid?

Answer:

This is a great question!  Just because you and/or your organization have a contract with ABC Health Plan does not mean you will be paid for the services you render.  Now you have to do your due diligence to make sure that you have most of the information needed to administer this Health Plan.  Obtain access to their website, review their online reference materials (Provider Manuals, clinical policies, billing requirements).

Look to develop an Operations Memo that will highlight specific information important to your staff.  Make sure you these key areas:

  1. What services is your organization contracted for?  If contracted for higher levels of care (IOP), what is the per diem rate, billing requirements for this service?
  2. Which clinicians are considered “in-network” for this insurance plan
  3. Provide an overview of the various product lines offered in your area, copies of ID cards
  4. Customer Service phone numbers for Intake, Clinical Authorizations, Claims follow up
  5. billing specifics, including mailing address and electronic Payer ID information.

Make sure your administrative staff checks that Payer’s website often for any updates and distributes those updates to the appropriate staff within your organization.

Remember the old carpenter saying Measure twice and cut once!