Entitlements and Insurance

Entitlements and insurance are two of the most common partial payment methods practices encounter on a daily basis. Each entitlement and insurance policy grants the holder different benefits, so it is critical to understand the differences between the two.

Entitlements 101

Entitlements guarantee access to a certain range of benefits by either established rights or by federal or state legislation. Entitlement benefit programs are not just restricted to healthcare, and include Social Security Disability Insurance, Social Security Retirement Income and Medicare. Some of the common entitlements you will encounter at your private practice include Medicaid, Medicare, TRICARE and CHAMPVA. 

Every practice chooses to see patients with certain types of insurance or certain entitlements. Since each entitlement has different requirements, they each offer a certain amount of reimbursement to your practice. On average, Medicaid only pays 60% of what Medicare pays. Medicare already only pays a portion of the “retail” value of your services, so if your patient sees a large number of patients with entitlements, you will also need to see patients who pay in full to offset the cost.

Entitlements vs. Insurance

Unlike insurance, entitlements are either promised or needs-based. Medicare is a federally guaranteed health insurance offering for adults who are 65 years or older or disabled. Anyone receiving Social Security Disability Insurance payments will be able to use Medicare after 24 months of benefits. Medicaid, on the other hand, is needs-based. Medicaid is a state program that also receives federal funding. It is used to provide healthcare for low-income people.

Insurance, on the other hand, can be purchased by individuals through a variety of sources, whether it is their employer or the ACA exchange. Most private practices choose to accept at least one or two types of insurance, but not all of them choose to accept Medicare and Medicaid.

Reach Your Patients More Effectively with Help from Vetters Enterprises

Vetters Enterprises specializes in practice management, revenue cycle optimization, and private practice business support. We can perform detailed assessments of your practice or facility and identify potential issues. Let us keep your business as healthy as you keep your patients! Give us a call at (443) 352-0088.

Credentialing 101

Setting up private practice billing can be an intimidating process, especially if you aren’t sure where to start. The first step of the process is always credentialing with insurance companies so that you will appear on their website, in their brochures and in their patient information booklets as a qualified provider. 

Why is Credentialing Important?

If you are not credentialed with a certain insurance provider, you will need to bill the company as an out-of-network provider. Many times, insurance companies will deny these claims and the patient will be stuck with the bill. Most government-based insurance companies like Medicaid, Tricare and Medicare will not pay for any out-of-network services. Practices without credentials will not be able to attract as many patients and might lose patients due to steep out-of-network bills. 

The Basics of Credentialing

The credentialing process typically takes from 90-120 days. Before you get started, make sure that you have the following in place:

  • A separate tax ID number for your practice
  • Malpractice insurance
  • An NPI number
  • A state license for the state you are operating in
  • Knowledge of your taxonomy code if you plan on treating Medicare and Medicaid patients
  • A profile on CAQH.org, a very common credentialing database that most major insurance companies look at
  • A practice location and address

When you are ready to begin the credentialing process reach out to Vetters Enterprises for assistance in managing all the nitty gritty details, or start by contacting the insurance companies that you want to be credentialed with to get applications. Always review contracts before you sign them so that you are familiar with the documentation standards, claim submission standards, appeals processes, free schedules, CPT codes and diagnosis codes. Once you are an approved and credentialed provider with an insurance company, you will gain access to their online provider website. Online tools are a great way to keep track of claims and appeals as they occur.

Need More Assistance?

There’s no denying that the credentialing period is a daunting and lengthy one, which is why Vetters Enterprises is here to help! Looking for a way that your practice can alleviate the stress of having to go it alone? At Vetters Enterprises, we’ll manage everything and take care of all the nitty gritty details during your credentialing period, so that you can get back to what is most important – taking care of your patients.

Vetters Enterprises specializes in practice management, revenue cycle optimization and private practice business support. We can also perform detailed assessments of your practice or facility and identify potential issues. Let us keep your business as healthy as you keep your patients! Give us a call at (443) 352-0088.