Third Party Billing

Purpose: 

To accommodate the occasional third-party payer, and ensure all requirements are obtained prior to client Start-of-Care to ensure proper billing and reimbursement.

On occasion, Recover Care at Home may make the decision to engage in a client-specific third-party payer contract (i.e. worker's compensation, auto insurance, etc.) to serve the needs of the community. This must only be done with the approval of the Recover Care Director.

Regulation: N/A
Policy: N/A

Measurement:

  1. 100% of invoices sent to third-party payers will be paid in full

Process:

  1. Prior to any services being provided, Recover Care at Home must:
    1. Send contract to Director of Contracting and Credentialing for review and indicate:
      1. Client Name
      2. Anticipated SOC date
  2. Director of Contracting will notify the billing team, via email, the following information:
    1. Client Name
    2. Third-Party Billing Company
    3. SOC Date
    4. What items are required for billing (items on the invoice, supporting documents, etc.)
    5. Attach a copy of the contract
  3. Once Director of Contracting has reviewed and approved the contract, RCH Team Coordinator will:
    1. Add the payer in ClearCare
    2. Review the contract to confirm what supporting documents and invoice details are needed to bill payer correction (auth #, PO #, TIN,  care notes, assessments, etc.)
    3. Review timely filing requirements and ensure process is setup to bill correctly
  4. Ensure the client Service Plan reflects the correct rate, as defined by the contract. If the rate is different than the defined rates, the SOC nurse can simply cross out the standard rate and hand-write the correct, agreed-upon rate on the service plan.
    1. If rate is different than standard rate, Team Coordinator will update contracted rate in client's Billing Policy
  5. If the payer requires authorization for provided services:
    1. Team Coordinator will contact the payer sources for authorization. Once authorization has been obtained, Team Coordinator will update the authorization in the client's Clear Care profile and scan the authorization into the client's record, named: "LName_FName_Authorization_Ex. XX.XX.XXXX"
    2. Team Coordinator will notify the Clinical Manager and RN Case Manager of the authorization start date, including the services and hours/visits authorized
  6. If the payer requires ongoing authorization for provided services:
    1. Recover Care at Home Team Coordinator will run "RCH - Authorization Tracking" Report in Clear Care weekly on Mondays to identify expiring authorizations in the upcoming month
    2. Team Coordinator will contact the payer sources for authorization. Once authorization has been obtained, Team Coordinator will update the authorization in the client's Clear Care profile and scan the authorization into the client's record, named: "LName_FName_Authorization_Ex. XX.XX.XXXX"
    3. Team Coordinator will notify the Clinical Manager and RN Case Manager of the authorization start date, to be able to continue services, including the services and hours/visits authorized
  7. Invoices and supporting documents, will be submitted monthly by Billing Specialist, on the standard monthly billing schedule, unless otherwise advised
  8. Billing Specialist will track payments as usual and engage the Director of Recover Care at home, in the event there are any late payments