I am trying to get a work flow together to do some well visits (haven’t decided exactly what I will do in terms of in-office/telewell, etc.). I was trying to compile the national carriers in one place. What I have thus far:
UHC- covers telephone encounters
Aetna- Covers Telewell with Part 1 as 9921X (POS -02 MOD -95)
Second part in-office with physical exam 9939X
This is exactly what I’ve been thinking we need, but I don’t know if the “rules” for each company are actually *national/universal. *
Does anyone know? And now that I’ve been made aware of ERISA, do some companies have both ERISA and non-ERISA plans?
I was dreaming of a spread sheet with all of this info: ins co/plan, E/Ms & CPTs covered, modifiers used, POS code, etc.
My understanding is that it is both carrier and plan specific. If they are self-funded, they are allowed to opt out of any of the new COVID-19 policies.
We have not started telemedicine Well visits, but for all of our telemedicine sick visits, we have been calling to verify whether the plan is fully funded or self-funded. If they are fully funded they are covering what the main carrier (ie UHC) is covering. We have a spreadsheet where we are tracking this information by carrier and then by employer so that we don’t have to call every time and are documenting whether fully funded or self funded so we know for future COVID-19 policy changes.
We have found that the answer you get is very dependent on the way you ask the question so we developed a flow sheet for our billing staff to use to help direct them to the actual question we are asking. I have found many insurances have not equipped their staff with easy access to what plans have opted in or out and you often have to push to get the information. Many try to just read you what the plan typically covers and not look at whether they have opted out on the new policies. Attached is our flow sheet of how we ask the questions.
This is a very good flowsheet and explanation that Cathy has posted above.
Having a summary of “major payer policies” works but will bite you if you aren’t careful. Remember that fully funded plans have to follow the policy of the carrier. Self-funded do not.
Remember: self-funded=ERISA=ASO=TPA=self-insured= can do WHATEVER THEY WANT. You cannot rely on the carrier’s policies (ie: United) even though it says "united on the card. This is where the flow sheet is invaluable. According to Chip, this is very regional and many areas of the country may not have very many of these. Where I am (Texas), these represent >75% of commercial plans.
On the other hand: fully funded=state-regulated=department of insurance=DOI=non-ERISA. These folks have to follow national policy and are generally easier to verify.
We have found that the elig and verification process for many of these the self-funded plans is just so bad right now. Some you can’t even get through. Others you get through to, and they don’t even understand your question. We therefore have occasionally made “best estimates” and sent claims without being able to verify telemed eligibility. When we have to wait for 30 min for verification, it is time prohibitive. While inexcusable, it is what it is. Good luck out there. #wildwildwest