The Voice of the AHLC
HOW TO BECOME A PARTICIPATING PROVIDER: BEFORE YOU APPLY How many clients come in with insurance coverage for wigs and where is the nearest in-network provider of wigs? If you only have a few requests per year, it may not be worth the investment of time and money to become a provider. If there is already an established provider in the area, it may be more difficult to get provider status. However, if you receive many requests and there are no local providers, you will want to note that on your application. APPLY FOR AN NPI NUMBER You can apply for an NPI (National Provider Identification) online for free at https://www.nppes.cms.hhs.gov BECOME HIPAA COMPLIANT All medical professionals are required to follow federal privacy (HIPAA) guidelines. To learn what is required to create your company’s HIPAA policy and what standards you’ll need to follow Visit https://www.hhs.gov/hipaa/index.html HOW TO APPLY • Visit the insurance company’s website to learn how to apply to be a new provider. You may fill out an online application or call them directly. • Make sure to note the need in your area for your specific services. • Realize that insurance companies may not be accepting new providers and you may have to wait to apply again. Document every conversation you have and call back every few months to check if they are accepting new providers. • If you are not having success, have your clients or their HR department call and request that they consider you as a provider. • Before you commit, review the contract, and consider the contracted rate. Sometimes you can negotiate for a better rate, or an upgrade clause, which allows you to bill the patient for luxury features that cost more than the allowed amount. Do not sign a contract unless you feel the terms are fair.
WHAT IF I AM UNABLE TO GET A CONTRACT, OR DECIDE IT’S NOT A GOOD FIT FOR MY BUSINESS? THERE ARE STILL SEVERAL WAYS TO INCREASE YOUR BUSINESS FROM INSURANCE CLIENTS: • Look into a third-party provider, such as Multiplan, or a local in-network medical supply company that will “subcontract” you to provide wigs. • If there are no local participating providers, ask the insurer if they allow network gap exceptions. This allows the client to request reimbursement at the in-network rate, if there are no participating providers within a reasonable distance. • Offer a variety of products and exceptional service. Some clients may opt to pay for a wig out-of-pocket rather than deal with an inferior vendor who is in-network. • Offer services for wigs purchased elsewhere. Many in-network providers are not full-service salons, so they may be looking for an expert to size and style their wig. And they may buy a second wig from you! • Provide your clients with proper forms and help them fill out and submit their claims. • Honestly educate your clients on their insurance benefits and options. Do not mislead them into thinking they are going to be reimbursed if you know they may not. • Offer special pricing and incentives to your medical clients. • Accept flexible spending plans • Network with a provider in the area to exchange referrals. If you offer something they don’t, offer to send them insurance clients if they will send you clients they can’t service. Navigating health insurance for cranial prostheses can be a challenging but rewarding venture. Understanding all that is involved will help you decide if it is a challenge worth undertaking. Educate yourself on the ins and outs of health insurance coverage and you will be invaluable to your medical clients.
HOW CLAIMS ARE PAID Below is a common example of how a PPO might process a wig claim. The amounts are just samples. If a chemotherapy patient has an insurance policy that will cover one wig up to $500, and she selects a wig that retails for $500. She has both in and out-of-network benefits: IN-Network Out-of-Network Deductible $500 $1,000 Amount of deductible met $500
Out of Pocket Maximum $1,500
Amount of OOP Met $500
The in-network provider has a contracted amount with her insurer of $350. IN-NETWORK PATIENT COST: $70 UP FRONT PROVIDER RECEIVES: $350- $70 NOW AND $280 LATER The provider must accept the contracted rate of $350. The client will pay her 20% co-insurance at the time of purchase. The provider will then bill the insurance company and be paid the remaining $280. OUT-OF-NETWORK PATIENT COST: $350 - $500 UP FRONT, $75 REIMBURSED LATER PROVIDER RECEIVES: $500 UP FRONT The client will have to pay up front the entire $500 up front. $200 of her purchase will be applied to her out-of-network deductible. Her plan will then pay 50% of the remaining $300, so she will be reimbursed a total of $150.
Issue 29, Spring 2019
The Link Magazine is a quarterly trade publication for the Hair Restoration Industry, published by the American Hair Loss Council, www.AHLC....