About our billing and claims process
In an effort to help families with insurance reimbursement for therapy expenses, Skills on the Hill will obtain authorizations for therapy services (when required) and submit claims electronically to your insurance carrier on your behalf. This does not mean we have a contract with every insurance, as we are still Out-Of-Network with most insurance. However, your claims submission will be timely and our billing department will follow up on any unpaid claims issues. After insurance reimbursement, you will never be out-of-pocket more than our current self-pay rate for services (please see Fee Schedule).
Using the Verification of Benefits form, our billing office will verify your insurance benefits and talk to you about them via phone. Our billing staff is experienced with therapy services and they will be able to answer all your questions related to benefits, claims processing, as well as your billing statements. Please be available to them so that you can have all of your questions answered.
You will not be billed until your claim has been processed by your insurance. You will receive a statement from us every 28 days if you have a balance due. You will then have (5) days to review the statement and call the billing department with any questions/concerns about the charges. Unless there are corrections, your credit card will be charged for the full amount shown on your statement.
It is our pleasure to provide high quality pediatric OT services to your child(ren). We know that submitting the claims to your insurance for you relieves you of having to work on your own for insurance reimbursement.
Who to contact if you have claims or billing questions
For all questions related to your claims and billing statements for services, please contact our Billing Office at 202-424-2718 or firstname.lastname@example.org. Our regular therapy staff will not be able to answer your questions or discuss your insurance claims or your statements as they are not involved with insurance processing.
For our BCBS families
In most cases, the payment for services will be sent directly to you. Please be looking for your payment and deposit the check directly into your bank account. The billing office will verify with the insurance company the specific amount of the reimbursement paid to you, then they will send you a statement to reflect payments and charge your credit card.
Policy for Secondary Insurance
You must inform our billing office if your child has more than one insurance policy. The practice will verify with both policies to confirm which policy is primary. This is critical to getting any necessary authorizations and having your claims process correctly.
Please be aware that, if you have or decide to obtain secondary insurance, one plan will be primary for all claims. The determination of which plan is primary and whether any payment would be made by a secondary plan depends on the rules specified in each insurance plan.
Keep in mind that our practice will not bill secondary insurance for you. You can use your primary insurance EOB/EOP (billing statement) to submit to your secondary insurance per your secondary insurance instructions.
If you do not notify our billing office of more than one policy, you may end up being responsible for the cost of any services that are denied or processed incorrectly.
For questions, please contact our Billing Department at 202-424-2718 or email@example.com.
GAP; also known as: In-Network Exception, Network Deficiency Coverage, or Single Case Agreement
How to obtain authorization
Gap is not always an advantage to the family; particularly if there are out of network benefits available. Gap does not mean the family will have no patient responsibility or even a “lower” patient responsibility and in fact, the out of network benefits may result in less patient out of pocket responsibility if a high number of visits are anticipated. Everything depends on variables that are dictated in each plan policy; no two are alike.
- You must contact the billing office to coordinate how best to obtain the GAP authorization. The billing office may or may not be able to initiate the authorization for you. If you have to obtain the authorization yourself, the billing office will provide you with essential information you will need and offer to be on any phone calls with you as you initiate the authorization. Diagnosis codes and CPT codes are a critical part of the process to get a GAP to process correctly.
- The authorization must be in place prior to services if you want to have your services covered by insurance.
- The practice will keep track of the visits that are used and attempt to notify when the authorization needs to be renewed. However; the family must be aware of the GAP limits.
- As a courtesy, the practice billing office will submit the clams to insurance electronically so that all the required information is on file for the insurance to be able to process the claim.
Please be aware:
- Insurance may process incorrectly if the policy does have OUT OF NETWORK benefits available, even though the family has requested and obtained a GAP exception. You must make certain the authorization is specifically entered as a GAP and not a regular authorization. The authorization can often be entered incorrectly by the insurance authorization department. Circle back with insurance to double check that the authorization has been entered as GAP.
- Insurance may pay and then retract payment and reprocess for a different amount for any number of reasons, which may create an unexpected patient balance due.
- Insurance may deny payment for any number of reasons; you will be responsible for contacting insurance regarding denied claims.