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Five Things You Should Know About Your Insurance Contracts

Congratulations! You’ve completed the contracting process and are now an “in-network” autism treatment provider with one or more insurance companies. But do you really know what you’ve committed to? What your contract actually says? What terms and conditions you’ve agreed to abide by? Though you probably don’t want to admit it, the answer is probably: no!

Here are five things you MUST know about your insurance contracts:

Read the fine print - it IS important!

1. What are you actually contracted for? In other words, what services can you provide that the insurance company(ies) will pay you for? Though that may seem like a “duh” question, it is actually often not that straight forward. Some contracts specifically list both the billing codes and their “definitions” as an integral part of the contract. Having that information makes it pretty straight forward: you are contracted to bill exclusively for the billing codes/services listed in your contract. In some cases, however, billing codes are not listed creating some haziness. Do not accept this: contact the insurance company(ies) directly and make sure you get this much needed clarification. If you don’t know exactly what services you are (and potentially are not) contracted for, the chances of your authorizations and claims getting “kicked” are that much higher. And, after all, time is money, so don’t waste it! Get the information up front.

2. Who/what is actually contracted? Some insurance companies contract with each BCBA/licensed professional individually while others offer agency/group contracts, while yet others do either/or depending on certain criteria --which differ, by the way, from company to company. It’s important that you (as the practice owner/executive director/ clinical director) know which type of contract is in force. If each of your BCBAs/licensed providers is individually contracted, are they properly “associated” with your practice to ensure that payments are processed correctly and issued to the correct “payee”? Are you on top of tracking the status of each of these individual contracts ensuring they continue to be in “good standing”? Do you know what the negotiated billing rates are for each individual contract? Do not assume they are all the same.

3. When does your contract(s) renew? Each of your contracts was executed at a different time and has (likely) different renewal dates and (potentially) different renewal terms. If you want/need to change or amend anything in your contract, you will need to do it within the specific window defined in each contract (which, of course, is unique to each contract). Some contracts renew “as is” automatically if you do nothing, while others may require you to actively renew if you wish to continue to be an in-network provider. There may be other “issues” pertaining to renewal (e.g. rate change, service code additions/modifications, etc.) that can ONLY be addressed at this time, so keep track of when each contract is “up” and how much “advance warning” they give you to make any changes. If you miss it, the window will be closed until your next renewal date which may be a year or more down the road.

4. Are there additional documents that include terms and conditions you have agreed to that you don’t know about or have? Most companies will send you the contract itself but not any additional documents that are “incorporated by reference”. That’s their fancy verbiage for “it was referred to in the contract, so it’s an integral part of the contract to which you are bound, but go find it yourself.” The primary document ”incorporated by reference” is usually the companies’ Provider Manual. Get your hands on it and read it! The Provider Manuals include important information about your working relationship with the insurance company that is not in the contract. Don’t get caught in a “I didn’t know I was supposed to do THAT!” situation… It could cost you dearly.

5. Your are an “in-network” provider… But, do you know which plans you are actually in-network with? Insurance companies often operate under numerous “brand” names as well as serving as third party administrators for various self-funded plans and other carriers. So, when you complete the contracting process with an insurance company you are likely to be able to accept clients from a list (and often a long list) of affiliated companies. Do you know who they are? If not, you may be turning away prospective clients unnecessarily and losing valuable revenue.

These are just a few of the many important things you need to know about each of your insurance contracts. The best way to avoid unpleasant surprises is, at minimum, to actually read your contracts. If you have questions, something is unclear, or you want clarifications, contact the company’s contracting representative or seek out professional help. What you don’t know can (most definitely) hurt you!

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