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hi everyone and welcome to episode 4 of ask a biller I'm Dylan the medical billing specialist for smart billing pro here at simple practice and I'm Maggie I'm an insurance specialist here at simple practice today we will be discussing client payment types we will go over deductibles coinsurance co-pays and out-of-pocket maximums following this video we will host a live event to answer your questions about client payment types and remember that if you have questions specific to insurance features in simple practice we offer a class every Tuesday at 11 a.m. Pacific Standard Time and Thursday at 3 p.m. Pacific Standard Time to walk you through getting started we've been getting a ton of questions about this particular topic so we're going to start by simply going over some terms and then we're going to address some more specific questions that our customers have had the first that we were going to cover is the type of plan your client has and how to interpret what's listed on their ID card this will help you understand how you're going to manage your clients payments so a verification of benefits is still super important but at first glance your clients ID card can tell you a lot of information first the ID card should have the plan type listed on it the plan type won't form you whether or not your client is eligible for out-of-network coverage with plan types there's a lot of acronyms to decode the most common plan types are PPO which stands for preferred provider organization clients can see in network or out-of-network they have flexibility to choose whatever provider they want to see then next we have HMO which is health maintenance organizations here clients can only see providers that are in network and it is required to have an assigned PCP or primary care physician for all your referrals referrals may or may not be required for behavioral health a POS plan is a point of service so like an HMO and that they have to have an assigned primary care physician and that they need referrals but they can see providers that are out of network and an EPO or an exclusive provider organization is where they can only see doctors that are in network but they don't need referrals and it's not required to have an assigned primary care doctor okay your clients ID card may also help you determine whether or not your client has a copay for office visits every ID card is different so there's no standard you can expect but many will have a small summary of their coverage on this card preventive indicates that there's no copay for medical services that are considered preventive so annual checkup annual lab work mammogram etc er equals emergency room and OV e stands for office visits you never want to just go off what is on the card you always want to verify coverage based on the CPT codes that you're going to be providing but this is a great place to start other language that you can expect to see on the clients ID card are shown on this slide so the most notable here are pcp which is primary care provider coin stands for coinsurance dead for deductible HDHP is high deductible health plans and there will be some additional accurate acronyms on there for pharmacies as well now let's get into the different payment types you can expect to see we are going to be covering in network examples these scenarios will apply to the pairs that you are paneled with the first and easiest one to understand is co-pays so a copay is basically a cover charge to get in to see a provider this will cover the charge for the office visit but might not cover additional services provided during the appointment if there's any kind of additional testing or you build other services it will be a separate charge that a copay might not cover they're generally broken down by specialist or primary care primary care usually being a cheaper option and a copay you will want to collect at the time of visit and then bill the insurance your entire private fee and for an example let's say your session fee is $100 and your contracted rate is 90 you checked with the payer and the client has a 40 co-pay so you would collect the $40 upfront and then you would build a full $100 fee to the insurance they will then reimburse you the additional $50 to total $90 and you'll write off the final ten the next payment type to consider is deductibles a deductible is a set amount that your client pays out-of-pocket towards all their services they will have to meet this amount first before the insurance kicks in co-pays generally do not go towards a deductible and it's very important to know what your contracted rate is so you know what to charge your client payers generally won't share this information with your client so clients with a deductible usually have no idea what they are going to have to pay for a particular service when they're walking in the door it's also important to remember that deductibles do not roll over at the end of the year so let's say for example your client has a fifteen hundred dollar deductible your session fee is $100 and your contracted rate is ninety dollars the client will pay you $90 directly you will submit a claim for the full $100 to the payer and the insurance payer it will keep track of the services and not the actual payments that you are responsible for making sure that the fees are collected and you were going to write off ten dollars so this is how billing this client will work until they've accumulated a total of fifteen hundred dollars worth of services then coinsurance will kick in and coinsurance is the predetermined percentage that the client will owe okay for example your session fee is $100 and you know your contracted rate is $90 the client already met their full fifteen hundred dollar deductible and the payer told you that their coinsurance is eighty twenty this means that the client will owe you eighteen dollars which is twenty percent of the contracted rate and the payer will then reimburse you seventy two dollars which is 80% of the contracted rate and again you're going to write off that final ten dollars all right everyone and back by popular demand charlie is here to help you understand the different payment methods your client might throw your way shoot there charlie here every time Charlie chess rolls around we decipher another item in the odd language of insurance 'yes this week on Charlie's chats we're going to talk about health savings accounts flexible spending accounts and health reimbursement accounts aka HSA FSA and HRA what do these acronyms mean and why do you need to know about them well these are all different types of payment methods offered by employers and payers in an effort to curve the cost of spending on health care these accounts usually compliment plans with high deductibles where the client would have to pay a considerable amount out-of-pocket first let's talk about the HSA a health savings account is essentially a debit card for health care expenses your client and their employer may contribute pre-tax money into this account to go towards qualifying care related expenses only certain types of coverage allow supplemental HSA your client should have a card for their HSA and they will have ownership over this account it will not be directly connected to the payer they're covered by it is entirely Supplemental through their benefits you'll charge this car just like you would a debit or credit card you can use simple practices super convenient payment methods strike next FSA's flexible spending outs are owned by the clients employer but are held in the clients name and both parties can contribute pre-tax dollars to the account ownership is what distinguishes this type of account from an HSA there's also more flexibility about the type of coverage a client can have the plan doesn't have to meet specific qualifications but the expenses must be health-related FSA vendors will have a list of applicable expenses and your client should have an FSA card that can be charged in stripe as well last but not least the HSA a health reimbursement account is different from the first two in that your client won't have a card that they can charge services to the account generally must be integrated with the client's insurer and reimbursements will be issued only after services have been billed and processed the account will be held in the clients name but deposits into this account are made only by the clients employer clients may need to submit invoices in the Obi's to their human resources department in order to be reimbursed for out-of-pocket expenses now I know this is a lot of information so if you need a refresh head to our blog where we've provided a downloadable list with everything you need to know about HSA FSA and HRE I hope that makes the insurance part of your practice a bit simpler so until the next Charlie chats here's Maggie and Dylan all right thanks for clearing that up charlie the last element of payment types that we're going to cover is the out-of-pocket maximum and for once guys this is exactly what it sounds like every benefit plan will have an absolute out-of-pocket max that the client will have to spend of their own money out-of-pocket maximums can vary a ton depending on the clients coverage in network co-pays deductibles and coinsurance payments all go towards this network out-of-pocket max and on this topic cheryl from our facebook community added that she had some trouble with knowing when a client has met their out-of-pocket maximum I've had this happen a few times and the only way I found out was when reimbursement went to my full contracted rate but the time that happened my client had paid sometimes up to four co-pays they didn't need to pay and I've had to refund those funds Cheryl that's a great point and I'm sure a lot of our customers have the same concern so since you might not be privy to the other health care expenses your client is accumulating the best way to keep track of this will be by checking the client's benefits before you start treatment that way you'll have an idea of where the client is or how much they've met of their out-of-pocket max or deductible for the year and here's a little smart billing pro tip we also recommend periodically checking in with the payer if this is a client that you have a long-term treatment plan with we can't guarantee that this won't happen but if the payer has an online portal it's good to keep track of this info and keep record of it and your clients overview in simple practice and we had another question from Maria regarding a Kaiser deductible I don't understand why Kaiser deductibles show up as denied I was told it's a Clearing House issue and that it's being worked on but as a therapist I like to understand the rationale behind things Maria this is a great question and I can definitely appreciate that a lot of our customers are concerned about this as well what happens when you see a denial status that should say deductible is that our automated system is interpreting a zero dollar payment from the payer as a denial when it's actually a zero dollar payment because the client owes you their deductible when this happens you will need to go through and add the write-off amount for each session so that the full session fee is accounted for and then the system will recognize that this is a deductible and the status will update automatically alright everyone that's all we have for you today thanks so much for tuning in and if there's anything that you still have questions about regarding client payments don't worry we'll be hosting a live event two weeks from now on May 17th we'll be sharing the link to register for that webinar right here on our blog and remember if you have questions about your simple practice account we offer a bunch of resources and live classes to help you out to sign up for a class go to support simple practice comm and while you're there take a look at some of the videos and guides that we've put together to make using our software a breeze also if you like the shirt that I'm wearing and want to get one for yourself check out our simple practice swag shop at this link and there are plenty of other great items for your friends and family and the best part about it is that all proceeds go towards Ocean Park Community Center a nonprofit organization headquartered here in our home of Santa Monica alright that's all we have for you today thank you so much for joining us and until next time keep it simple