As a healthcare center dedicated to serving your community, your organization’s billing practices impact the people around you. Are you following the most effective and efficient billing procedures?
This article explains the types of community health network billing and how it can work most productively. At the conclusion of the article, you’ll find an excellent resource for medical billing to assist your community health billing department.
What is Community Health Network Billing?
Community health network billing occurs when community healthcare providers submit financial reimbursement claims for their services and request payment. Billing should follow a certain path to ensure correct reimbursement, which is explained in more detail in the next section.
If the patient doesn’t have insurance, they are directly billed for services rendered. Or, if they have coverage through a government program like Medicare or Medicaid, the appropriate organization would be billed in lieu of an insurance company.
What are the Types of Community Health Network Billing?
Community health centers typically bill two main types of organizations: private and public. There are also subcategories within public health insurance. Here’s an overview of these categories of healthcare coverage organizations and how reimbursement occurs.
Private Health Insurance
Approximately 65% of U.S. healthcare patients have private health insurance. Private coverage isn’t provided by a state or federal program and is instead handled by a private insurance company. The insurance company either charges the person directly or makes coverage arrangements with their employer or another entity.
Healthcare bills should go to these private insurance companies first. As a healthcare provider, you’ll also need to establish whether you are in-network or out-of-network for the patient/payer.
Out-of-network providers are associated with higher costs for patients due to a lack of pre-negotiated lower prices. In-network providers can typically offer lower costs due to arrangements with large patient groups via insurance companies.
In some cases, multiple private insurers must be billed for the same services. This type of multi-insurance provider billing requires extremely detailed and careful tracking for proper reimbursement. Consider using digital platforms that make this process as smooth as possible.
Public Health Insurance
About 35% of patients in the U.S. rely on some type of public health insurance coverage. For these patients, community health centers should bill the appropriate government entity for healthcare services.
Medicare Billing
Medicare is a government program that covers people over age 65 and those with certain disabilities and conditions. Healthcare providers must apply to become participating Medicare providers, which may take 60 to 90 days for approval before becoming eligible for reimbursement.
Medicaid Billing
Medicaid is technically a government assistance program rather than an insurance program, but most people view it as a type of insurance. It provides coverage for low-income people who otherwise might struggle to afford the healthcare they need. Medicaid is a combined state and federal program, which means you must apply at the state level and also follow federal regulations.
What are the Differences Among the Types of Community Health Network Billing?
Each type of billing has its own requirements and procedures. Private insurance involves more than 1,000 private insurance companies across the U.S., a number that has been steadily growing over the past decade.
Most of the nation’s popular insurance companies serve certain geographical markets or established service areas. Every company also follows its own set of rules and routes to payment, resulting in a highly complex reimbursement environment for any community health center to handle.
When it comes to Medicare/Medicaid, the coverage is more centralized but can be just as confusing. Plus, your healthcare center has the added pressure of potentially losing its eligibility to receive government payments if you inadvertently break the rules. As a federally-qualified healthcare center (FQHC), you must stay within regulatory compliance and use public dollars wisely.
The federal government regulates Medicare provider payment rates for all covered healthcare services. These rates are standardized and set in advance, so your expected payment rates should be fairly clear. Medicaid follows state rules in addition to federal rules, adding another layer of complexity.
Community Health Network Billing: How Altruis Can Help
How can your organization meet so many billing challenges and serve its community? Many healthcare centers like yours are turning to outside billing partners to help handle the workload.
For example, many FQHCs miss out on reimbursements for Medicare Advantage patients due to misunderstandings and procedural missteps. Your organization may have similar challenges you could overcome with better billing practices and optimized revenue cycle management through Altruis.
Altruis helps you tackle payment issues so your organization can focus on patient care instead of billing issues. We’re experts in the industry who use the latest technology and techniques to maximize profitability and minimize hassle.
To learn more, schedule a call with us. We’d love to show you how other community healthcare centers are providing outstanding patient care while Altruis optimizes its billing.
