The process of creating, submitting, and processing insurance claims (via the CMS 1500 form) is a bit of an art, and a bit of a science. The process of completing the standard fields of a CMS 1500 form can be straight forward, but there can also be nuances and complications across the cycle of a claim.

Moreover, as your client load increases, managing insurance billing can take an increasing amount of your time. Spending the time on billing, although an important task, takes away from providing other revenue-generating services to your clients.

Determining how you’ll manage insurance billing in your practice is an important consideration. While you may choose to manage your own billing, you may find that hiring a biller may be more practical for your business. In this article, we review the responsibilities that are typically required for billing management, the benefits for hiring a third party biller, and important considerations prior to hiring out.

Insurance Billing: Process and Time Expectations

There are several steps that go into the insurance billing process. View the revenue cycle management below, along with estimated time expectations for each step. Clearly understanding how you will bill insurance, and how much time it will require, will help you determine if self-managing your billing is the right decision for your wellness business.

1. Eligibility Checks

(Time 5-15 minutes per client)

Managing insurance billing responsibilities begins with the very first client interaction. Prior to your initial consultation with a new client, it’s important to complete an eligibility check, otherwise called “benefits verification.” This typically involves calling your client’s insurance provider to verify that the client is covered for your wellness services, and obtaining other relevant information such as copay and deductible amounts. Many wellness providers choose to hire an office assistant, or use online benefits verification tools to help minimize time spent on eligibility checks.

2. Create CMS 1500 claim

(Time 10-15 minutes per claim)

After an initial consultation with your client, you’ll need to create a CMS 1500 claim. This is a standard form used across insurance payers to submit services for reimbursement.

The CMS 1500 requires the following information:

• Client Personal Information: This includes all the basics you would get on an intake form, such as name, date of birth, gender, address, and relationship to the Insured.
• Client Billing Information
• Referral Information: Some insurance companies require that you include any information about the referring provider, like their name and NPI number.
• Your Provider Information: This includes your NPI, In-Network Provider ID, and additional information as required by individual company.
• Your practice’s information: You’ll need your location NPI and address.
• Insurance Policy Information
• Diagnosis: Make sure to include all appropriate CPT and ICD-10 codes

Creating claims can take 10-15 minutes once you are familiar with the forms. Even more time can be saved when using an EHR platform that integrates with your insurance claim tool.

3. Scrub CMS 1500 Claim

(Time 5-10 minutes per claim)

After your claim is created, it’s important to review it for accuracy. Claims with errors will be denied, and cost more time down the line for reprocessing. If using a clearinghouse, such as Office Ally, claims will be automatically scrubbed, and the submitting provider notified before the claim can be sent to the insurance payer. If manually scrubbing claims, expect to spend 5-10 minutes to ensure the form is complete, information is correct, and the right diagnosis / CPT codes have been used.

4. CMS 1500 Claim Submission

(Time 5-10 minutes)

Submitting a claim can typically be electronically processed through an insurance company’s portal, a clearinghouse, or via mail. If you are in-network with multiple insurance payers, then you may find yourself using a combination of these options. Claim submissions may only take a few minutes, depending on which way you choose.

5. Claims Follow-Up

(Time varies based on number of claims)

Once your insurance claim is submitted, it will typically be a few weeks before the insurance payer processes it. If the claim is approved, then you’ll be able to check within your company’s portal, or your clearinghouse, to review the reimbursement details. Running diligent checks and reports are necessary to ensure:

• Claim reimbursement amount by the insurance provider is correct, and matches your contract rate
• Review any client-owed responsibilities (copays, deductible amounts, non-covered portions)
• Ensure that your payment was issued to your bank account and/or you cash the reimbursement check

For denied claims, you’ll need to go through the process of understanding why the claim was denied. This could be an error on the claim form, and error on the insurance payers end, or your client does not have benefits for your services. Claims can be adjusted and then resubmitted to insurance payers.

The amount of time that you spend on claims will vary based on the number of claims you submit each week/month, and how you receive your reimbursement. It’s best to block off time in your schedule each week to review your insurance reimbursements, and update your records and client accounts.

6. Accounts Receivable

(Time varies, and may be significant)

For any client-owed responsibilities, such as copays, deductibles, and non-covered portions of services, you’ll need to collect payment from clients. Some wellness providers choose to invoice clients remaining balances, whereas others may keep a credit card on file to charge owed amounts (and send client a receipt of payment). Depending on your practice policies, accounts receivable can require a significant amount of administrative work.

What is managed billing and what do third-party billing companies do?

Third party billing companies will handle the entire revenue cycle on your behalf. This enables you to focus on seeing clients, and is almost akin to having an assistant that is specialized to focus on your claims management.

Typically, you’ll grant your biller administrative permissions to your EHR platform. You’ll be responsible for completing your chart notes for your clients, as well as indicating the diagnosis codes to be used on the claim. Your biller will then generate your CMS 1500 claim, scrub it for errors, and submit it to your insurance payer through the proper portal. Your biller will also keep track of the status of your claims, and help you resubmit any claims that were denied or improperly reimbursed.

What are the benefits to hiring a biller?

Saved Time: Billing is a necessary, but repeatable activity that can take hours of your schedule each week. If hiring a biller is the right step for your practice, it can allow you to use your time more effectively by focusing on business growth and client care.

Enhanced Specialization: Billers that focus on dietetic and health coaching claims, e.g., work exclusively with dietitians and other healthcare practitioners stay abreast of changes in ICD-10/CPT codes, as well as best practices to help you increase success rates

Improved Accuracy: As billers handle thousands of claims, they are experts at knowing how to correctly complete claims. They will be able to make any adjustments to the claim and efficiently scrub for any errors, reducing the rate of denied claims.

Increased Profits: More claims that are properly filed and reimbursed means significantly less time spent in accounts receivable. The reality is, it can be very difficult to collect payments from clients for client-owed responsibilities. If your practice does not require (or cannot require) clients to put a credit card on file, then it can cost you time, and money, trying to recoup balances from clients.  

Important Considerations Prior to Hiring a Biller

How many claims do you process each week?

There is a fixed cost to claim submission, in terms of your time, if you manage your billing independently. Whether you are calling an insurance company about 1 claim or 100 claims, it will take you time to connect to the right person. With that being said, if you have a smaller client-load, and set aside the time each week to manage your billing, it can certainly be done in-house.

If you process a moderate amount of claims per week (10 – 25) you clearly have the ability to attract a steady amount of clients, and your time may be better spent on client-facing services. Blocking off large chunks of time in your schedule for moderate/high amounts of claims may ultimately be costing your practice money.

For group practices with multiple providers, insurance billing can quickly become time consuming and tricky. Filing claims correctly ensures the least amount of time spent on billing, with a successful reimbursement. With group practices, it typically makes sense to outsource insurance billing from an economics perspective, unless a) your biller does other admin work or b) you’re processing such a high volume that it makes sense to have someone in house paying salary and benefits.

Do you stay up-to-date on changes in insurance company reimbursements and evolving codes (e.g., new CPT codes for prevention)?

As a nutrition or wellness professional, typically your time is spent on client services and staying abreast of the latest approaches to nutritional care. Most likely, your background is not in insurance billing, and it may be challenging to stay up-to-date with the latest changes or requirements for billing.

Insurance billing and coding specialists on the other hand, are very well-versed in updates to the industry, stay abreast of updates in the industry. This means that in the process of scrubbing a claim, they can catch certain known denials and also help you with ensuring you have matched ICD-10 and CPT codes according to protocols and best practices.

How many insurance companies are you credentialed with?

If you work primarily with one insurance company, and do not have a need or desire to expand beyond this one insurance company, you have likely become an expert in managing their portal and billing process. In this instance, you likely have a consistent volume of claims from this one insurance payer, and can bundle your insurance work into reasonable chunks (e.g., in 2-hour chunks, 2-3 times per week).

However, if you’ve credentialed with multiple insurance payers, processing your claims can quickly become overwhelming. Even when using a clearinghouse, you may find that not all of your insurance payers are participaters — and you may need to use their particular portal for submitting claims (e.g., Navinet for United Healthcare).

Does the mental load of insurance billing weigh on you?

Perhaps the most important consideration when deciding to self-manage your insurance billing or outsource, is the mental load. Just because you are technically capable of managing your own insurance billing, will the mental load be too much for you to put on your plate? As an entrepreneur, it is always important that you are honest with yourself and delegate any tasks that really weigh you down. If your passion is working with your clients, spending a significant amount of your time during the week doing billing may feel like a dreaded task. So know yourself, and if this is one task you just can’t put on your plate, then it’s important to consider hiring a biller for your wellness business.

How much do billers charge to work with nutrition practices?

The typical range for third party billers in dietetics is between 5-9% of successful claims. This means that for many billers, they get paid for services only if and when you receive reimbursement for a claim. Some billers will include eligibility checks as a part of their services, while others will charge an additional fee per each eligibility check — this rate can be as high as $5 per eligibility check. In addition, some insurance billers will have a monthly minimum volume as part of their fees, to cover their operational costs. This minimum can range from $75 – $200 per month — meaning that you must process enough claims to ensure the biller will be reimbursed at least the minimum amount.

If you’re just starting out with insurance billing, and don’t have a high client load, you may not be able to guarantee the minimum for a biller. In that case, you may want to consider managing your billing in-house for a few months until you’re able to grow your client load. It may be cost-effective to hire an office assistant to help manage client scheduling and eligibility checks.

Insurance Billing with the Healthie Platform

Healthie is the all-in-one practice management platform designed for dietitians and nutrition professionals. All of the tools you need to run your business, such as client scheduling, charting, and billing, are all conveniently located in one platform. Easily add support accounts for a biller to your membership plan, for a centralized way to work with a biller (and maintain oversight with your finances).

In addition, Healthie has a direct integration with Office Ally for direct claims submission. Receive claim status and reimbursement details back from Office Ally automatically, and run billing reports within Healthie to efficiently keep track of your claims and reimbursements.