Handling Claims During Pending Contracting and Credentialing Status
As a healthcare provider, one of the critical aspects of running a successful practice is ensuring that you have proper contracting and credentialing with insurance companies. However, it is not uncommon for providers, especially those starting in a new practice, to have pending status with certain insurers. During this waiting period, there is a common misconception that holding claims for patients with pending insurance status will result in retro coverage once contracting is complete. This blog post will illuminate this misconception and explore the best practices for handling claims during pending contracting and credentialing status.
Understanding Retro Coverage
Retro coverage, also known as retroactive coverage, refers to insurance companies covering services provided before the effective date of a provider’s contract. If a provider sees patients and holds their claims until after the contracting and credentialing process is completed, the insurer will still reimburse those claims as if they were in-network services.
Commercial Insurance Plans and Retro Coverage
Unfortunately, commercial insurance plans generally do not provide retro coverage. What does this mean for your practice? If you hold claims for patients seen during the pending status, hoping they will be covered once your contract becomes effective, you may be disappointed. In most cases, these claims will either be denied outright or processed as out-of-network claims, resulting in higher out-of-pocket expenses for patients.
Federal Payers and Retro Coverage
Federal payers like Medicare typically offer retro coverage for a specified period, often covering services up to a year before the effective date of the contract. This can benefit providers seeking Medicare enrollment, as it helps capture reimbursement for services provided during credentialing.
Medicaid Plans and Retro Coverage
Retro coverage for Medicaid plans varies by state and insurance company. State Medicaid plans might offer retro coverage for up to six months. Managed Care Option (MCO) Medicaid plans (those offered through private insurers) may follow commercial insurance guidelines, not providing retro coverage. Therefore, it is crucial to check with each Medicaid plan to understand their specific retro coverage policy.
Best Practices for Handling Claims During Pending Contracting and Credentialing Status
Considering the potential lack of retro coverage for commercial insurance plans, here are some best practices to handle claims during the pending contracting and credentialing status:
Educate Patients: Inform patients with insurance plans still pending in-network status about the situation. Upon check-in, please provide them with a document explaining their options, including self-pay or billing the insurance with potential out-of-network expenses.
Obtain Patient Consent: Have patients sign a document acknowledging their understanding of the situation and their choice regarding billing options. This protects your practice from potential disputes in the future.
Communicate Clearly: Train your front desk staff to communicate openly with patients about their insurance status and potential out-of-network expenses.
Document Everything: Keep records of all patient interactions and consent forms, maintaining a clear trail of communication and patient understanding.
Navigating the insurance contracting and credentialing world can be complex, but ensuring proper patient communication and education during the pending status is crucial. Not all insurance plans offer retro coverage, so confirming each insurer’s policy is essential.
As always, please use this blog post as a starting point for your research. The information provided here is not one-size-fits-all, and policies may vary by state and insurance company. Always check with the individual insurance plans to understand their specific retro coverage policies.
If you found this information helpful, please leave any questions or comments in the section below. Thank you for reading, and take care!