HMO, PPO, and EPO Explained.

Do you ever wonder why you get an
out-of-network denial by an insurance that you participate with?

With so many plans out there it’s difficult to keep track of them all, and to understand whether your patient’s care is covered. It may be that you are enrolled with the PPO but not the EPO, or the HMO and not the PPO, etc.
Let’s clarify.

What is an HMO?
An HMO is a Health Maintenance Organization.
It is an organization of providers that are available within a plan and are dedicated to the member’s care.
This is referred to as the network.
With an HMO, a patient must choose a primary care physician and obtain a referral for any specialty care.
HMO’s were created as a means to reduce healthcare costs and decrease unnecessary paperwork, and will not provide coverage for any care received outside the network.

What is a PPO?
A PPO is a Preferred Provider Organization.
PPO’s are slightly more flexible, allowing a patient to choose to see any provider whether they are in the network or not, with no referral required.
Typically, the cost sharing is higher for out of network care and not all care is guaranteed to be covered.

What is an EPO?
An EPO is similar to an HMO.
An Exclusive Provider Organization, it allows patients to see specialist without a referral, and there is no requirement to choose a PCP, but the network of participating
providers is limited.
And, an EPO will not cover care outside the network at all.

What can you do?
When enrolling with a health care plan as a participating provider, be sure to inquire about all the plans available. Decide whether you will enroll with all plans, or
just certain ones.
Be aware of the reimbursements rates and how they vary if you do decide to remain out of network, and be sure to know whether you will reimbursed at all.
And keep an open line of communication with your patients.
Encourage them to get involved and keep themselves educated regarding what types of coverage they have.
Be open about out-of-network care that may not be covered right up front, and be sure you patient is aware that they may be responsible for full payment of any non covered care.

What should your patient do?
Your patient should be verifying you are in network before calling for an appointment, but to protect yourself, always verify your network participation with a patient’s plan before seeing the patient to avoid surprises and missed revenue.


Don’t be a statistic.

Did you know that according to Medicare’s CERT Program that 54% of payments made to chiropractors were made in error?

Are you doing all you can to avoid being an error rate statistic?


Find out below.

We all know the basics such as, always use the AT modifier for active treatment, always code the subluxation as primary diagnosis followed by the corresponding medical condition, include an initial treatment date, but there is so much more to be aware of when it comes to billing requirements.

Most of the errors found by the CERT Program were related to documentation, including a lack thereof, and can be easily avoided by making use of the educational and informational resources provided by CMS.

Here is a great article to keep you in the loop regarding documentation requirements:

And check out this great guide on common misconceptions regarding billing Medicare for chiropractic services:

It’s easy to get into a routine and lose track of changes. Keep yourself in the know by making use of all the tools available to you, protect yourself from an audit, and always stay informed!




Keep your A/R in check.

Follow these simple steps to keep your A/R from getting out of control:

Develop a strict regiment.

  • Set a routine and stick to it.
  • Print A/R reports on a set day each month, and create a schedule to address balances in order of days outstanding, starting with the oldest.
  • Tackle insurance balances one payer at a time to avoid jumping back and forth.
  • Track progress with notes, including dates and names of insurance representatives that you have spoken to, and actions taken.

Keep a database of useful information.

  • Maintain a folder for each insurance company. Include phone numbers, payment policies, fee schedules, and common denial reason codes for quick and easy access and keep it handy when investigating outstanding insurance balances.

Communicate results.

  • Get your staff involved by showing them the fruits of their hard work, and consider tracking success rates to generate excitement.
  • Celebrate when a milestone is reached, such as clearing balances over 120 days. Employees feel more motivated when they can see that their actions are producing results.
  • Track instructions, ideas, and actions taken in the notes section of your software for time saving availability.

Be proactive.

  • Avoid denials and delays for unlisted procedures by becoming familiar with the payer’s policies and if documentation is required, don’t wait, send it with the claim right away.
  • Address appeals immediately and include all information that might improve the chances of payment right away. Don’t offer any opportunity for the payer to rebuff your appeal due to lack of information. Time wasted equals money lost.
  • Be upfront in communication with patients about collections policies, and don’t let balances build up. The higher the balance, the less likely a patient is to pay it, whereas smaller balances are perceived to be more manageable even when collected more frequently.


Don’t let those dollars slip away. Implement these tools as part of your routine and you will soon see those overwhelming outstanding balances shrink and stay manageable.



Tips to Improve your Front Desk Collections

Within a health insurance environment that is constantly changing with new plans, higher deductibles, and varying reimbursement structures, the need to maximize your collections at the front desk remains key to a successful practice.
It is now more important that ever to collect the patients financial responsibility up front.
Over 11 million Americans are now covered by high deductible health plans and the financial liability has shifted to the patient at an increase of about 70% from just a few years ago.
Here are a few tips to keep your front desk focused on patient collections:
  • Be diligent about eligibility. This includes verifying active coverage, co-payment/co-insurance/deductible amounts, and as well as provider participation.
  • Develop policies that are focused on collections. Post these policies and maintain consistency in expectations. Payment for services is due at time of service. Period.
  • Offer alternate methods of payment. Utilize technology and investigate mobile options for payment in addition to traditional credit card and check. Much of today’s practice management software offer a patient portal for electronic payments.
  • And never underestimate the effectiveness of an incentive. Offer a prompt pay discount, or a signed payment plan agreement for larger balances.
  • Most importantly: Train your staff! Creating these policies and procedures is a great start but you will need to impress upon your staff that these are not optional. Get into a routine and no exceptions. Repetition leads to efficiency. 
The point is if you develop a relationship with your patient and maintain strict, consistent policies and procedures regarding payment expectations, collections will become a breeze. 
Your bank account will thank you for it!

Aetna announces strictly electronic claims.

Did you know…?

Aetna announces that as of January 1, 2017 they will no longer accept claims on paper.

Aetna states that per their participating provider standard contracts, all providers agree to submit claims electronically and it is now a requirement across the board.

This applies to re-submissions, corrected claims, and secondary COB claims as well

They have issued instruction as to how to indicate a submission of a corrected claim and that is by entering a 7 in Box 22, or the Claim Frequency Code field of the electronic claim.

Electronic claims submission has been proven to increase work flow efficiency, and increase revenue. And we have all experienced paper claims getting lost in the “abyss” never to be received by the payer, with no recourse to prove timely filing. With plenty of choices in software and clearinghouses that are available today it couldn’t be easier. So, if you’re still filing claims by paper now is your chance to embrace the digital age, update your policies and procedures and reap the benefits. If you submit claims to Aetna, make sure you’re ready by January 1 to go electronic!


Stay tuned and stay in the loop with helpful hints from your friends here at HMB.


Avoid these seven common billing errors.

Seven Common Billing Mistakes

In our business, we see a lot of the same mistakes being made over and over. They might seem like no big deal, but over time it’s costing your practice money.

Some of the most common are:

  1. Failing to photocopy the insurance ID card. office-594132_1280
  2. Missing the claim filing limit.
  3. Misreading an EOB.
  4. Ignoring clearinghouse reports.
  5. Incorrect code usage.
  6. Lack of reporting.
  7. And most importantly: Failing to make your billing the most important job in the office.
Your medical billing requires full attention and dedicated time in order to focus on billing tasks and to avoid these common and easily corrected issues.
We at Help My Biller encourage all offices to:
Be organized.
Utilize clearinghouse and aging reports.
Stay web savvy and make use of online resources.
Track actions with notes; names, dates, and reference numbers.
And above all stay educated!


Does your ICD-10 documentation stand up? Follow these 5 tips.

We all know that the ICD-10 CMS grace period is ending October 1st, 2016. Providers need to be very clear and concise in their choice of diagnosis codes and in their documentation to avoid denials. The tips below will help you be sure your claims can stand up to an audit.


  1. Utilize evidence-based protocols for assessing the patient’s needs. These guidelines encourage accurate documentation that will support your diagnosis choice. And quality does not equal quantity in this case. Under-documenting or over-documenting can result in overlooked or inaccurate diagnosis codes.
  2. Document to support medical necessity. Make sure to document the reason you performed the service, outline your treatment plan for each diagnosis, and as well as clinical progression.
  3. Be sure to choose the code with the greatest degree of specificity, that accurately describes the patient’s condition. If your patient has sciatic pain on the left side, be sure to choose the code that specifies sciatica, left side.
  4. Utilize peer review groups and internal auditing to stay ahead of the game. Sit down with staff and compare claims to chart notes. If there is a pattern of diagnosis related denials, this is a great opportunity to look for areas of improvement.
  5. Avoid pattern documentation and coding. Stay away from the “cloning” method of documenting, or copying and pasting from previous chart entries. The chosen ICD-10 code must correctly reflect the patient’s actual presented condition, and the documentation should support it.

Follow these tips to submit your claims cleanly the first time and beat the auditors!