ADVANCED MASSAGE INSURANCE BILLING CONTRACT
Please print and read thoroughly before agreeing and signing for services.
When Advanced Massage Billing Services has been accepted and contract agreed upon and signed, Lori A. Worrell will send an introductory welcome letter with a step by step guide for "Provider" to follow, along with all needed forms.
Advanced Massage Insurance Billing maintains the right to change, correct or delete entire or parts of this contract
at anytime without advanced notice until it has been signed and dated by all parties .
Insurance billing contract between Advanced Massage Insurance Billing (AMIB) /Lori A. Worrell hereinafter referred to as Lori Worrell and____________________________________, LMT, License or Certifion #: ______________or Company _________________________herein after referred to as “Provider”.
ADVANCED MASSAGE INSURANCE BILLING/ LORI WORRELL AGREEMENT:
I, Lori Worrell, agrees to provide the following services to the above named Licensed /Certified or Registered Massage Therapist or Company, “Provider.”
a. Inform “Provider” of all necessary forms needed for patient intake, such as, but not limited to Prescription, Initial Evaluations, Re-Evaluations, Progress Reports /Documentation, Insurance Company Contact Form, any required State Specific or Specialty Forms as well as collection forms when and if needed. Lori Worrell will also notify “Provider” by email or US Mail, a general information notice for “Provider” to know what to expect, what sort of cases they may accept and other pertinent information specific to their circumstances. Lori Worrell may supply all forms by email attachment to “Provider” for creating their office master copies or may suggest how these and additional forms may be purchased on CD for creating master copies.
b. Set up and maintain therapist and patient file folders with all patient and therapist information, including but not limited to copies of initial visit, prescription, collections, insurer communications, daily progress notes submitted by “Provider” payments, EOB’s and insurance rebuttals.
c. Contact insurance company/adjusters for verification of all types of cases except Workers’ Compensation Cases, within 4 BUSINESS DAYS of receipt of “Provider’s” required paperwork and information, or as soon as possible to get through to the insurance adjuster with proof to “Provider” if requested of any connection attempts.
d. Contact insurance adjuster for authorization for your office to treat a Workers’ Compensation case within 4 BUSINESS DAYS of receipt of “Provider’s” required paperwork and information, or as soon as possible to get through to the insurance adjuster with proof to “Provider” if requested of any connection attempts.
NOTE: “Provider” should obtain authorization or verification of coverage if “providers” patient is in a hurry to come in for treatment or if "prpvider" does not wish to treat the patient until authorizatoin or verification is obtained. However, “Provider” will, within 4 BUSINESS DAYS, notify and submit documentation of insurance company communications to Lori Worrell by fax or priority mail.
e. Lori Worrell will notify “Provider” of the communication results immediately by phone or fax, upon contact with insurer and will documentall insurance contacts, attempts at contacts and communications and results in patient file.
f. Lori Worrell will prepare the CLAIM with insurance company within 7 BUSINESS DAYS of receiving ALL of the required documentation requested above from “Provider”.
If for any unforeseen reason a claim cannot be completed, and submitted to the "Provider' for "Provider" to sign and send certified, return receipt requested, to insurance company within less than the 35th date from the first date of service, Lori Worrell will instruct "Provider" on how to
submit a 21 day notification with certified return receipt, (PROOF) to insurer to comply with the 21, 35, 75 day FL PIP Statute. (This ruling is for Fl PIP Cases only).
g. Contact “Provider” Insurer or Patient within 7 BUSINESS DAYS after receiving from “Provider” the EOB notification from the insurer for denied, reduced or delayed claim.
LORI WORRELL’S FOLLOW UP WILL INCLUDE:
a. Advising “Provider” of insurance adjuster’s reasons or excuses within 7 BUISNESS DAYS by telephone, fax, email or mail if “Provider” did not understand the EOB received by Insurer providing EOB is submitted to Lori Worrell.
b. Submitting copies of claims to patient’s attorney if one exists. Lori Worrell will charge the attorney $1.00 per page to be submitted to Lori Worrell for copying, filing and submitting copies to any attorney.
c. Submitting copies of claims to a secondary insurer or insurer at fault if in a state that does NOT have some form of No- Fault coverage.
No-Fault States are: Florida, Hawaii, Kansas, Kentucky, Massachusetts, Michigan, Minnesota, New Jersey, New York, North Dakota, Pennsylvania and Utah. There are those in other states that have the capabilities of choosing “Add On” No-Fault such as Arkansas, DC, Delaware and Maryland. All other states are what are known as “tort” states and the fault must be established or the patient must have purchased Med-Pay on their policy. Often patient’s insurance will cover medical bills and receive reimbursement from the “at fault" party either through their insurance company or attorney.”
d. Re-submitting corrected, disputed or denied claims to insurance company for reassessment or payment demand.
e. Submitting first, second and final notice to patient (but ONLY if and when permission is given by treating “Provider”)
Please note that if the FL 21 day notification rule or submission of claim is not postmarked no later than that 35th day from the first date of sercive, patient nor insurer are responsible and "Provider will NOT be paid whatsoever on this patient's claim. Therefore it is important that both "Provider" and Billing Service, Lori Worrell make sure this is done properly even if it is duplicated by both parties!!.
f. I, Lori Worrell, will do everything in my power to collect initial claims as well as follow up balances and to notify “Provider” of such actions. I will do my best to rectify any delay, denial or reduction of claims reimbursement. If I am personally unable to rectify it I will contact Vivian M. Mahoney to further advise. With final evaluation we will notify “Provider” of steps you may or should then take to rectify or prevent future problems or such circumstances as may have existed to cause denials, delays or reductions.
g. I, Lori Worrell agrees to keep all communication lines open, return communications as promptly as possible and in no longer than 7 BUISNESS DAYS, respond to faxes, emails or letters and otherwise keep the “Provider” well apprised of all aspects of their claims.
h. I, Lori Worrell agrees that if or when I should decide, for whatever reason, to dissolve billing services with this “Provider”, I will provide “Provider” a 14- BUSINESS DAY written notice. I also agree to immediately return all confidential patient documentation, billing and therapists records to “Provider” named herein by Priority Mail, Confirmation Delivery within 7 BUSINESS DAYS.
“PROVIDER” AGREEMENT:
To assure timely and efficient billing services from Lori Worrell, I____________________________ and /or my company__________________________ hereafter referred to as the “Provider” agrees to the following requirements.
FOR EACH NEW PATIENT VISIT “PROVIDER” AGREES TO PROVIDE A COPY OF:
a. Patient “Initial Evaluation (Intake) or History Form” and Specific Form for each type of case such as “Auto Accident or Personal Injury” form or “Workers’ Compensation” form for these type of cases. (Lori Worrell will advise which forms are needed and how “Provider” may obtain them).
b. Copy of Referring Physician’s “Prescription” Prescription must contain: patient's name, Manual Therapy Techniques, or Myofascial Release (UNLESS all you intend to perform is basic Swedish massage) and must contain the Duration, Frequency and physician's NPI #
c. “Standard Disclosure Form” OIR-B1-1571, dated 2004, Florida Auto (PIP) Cases Only.
Must be signed in BLUE INK by both PATIENT and PROVIDER on FIRST visit for Florida Auto Cases only. This form is to be completed including every procedure, modality and initial evaluation exam performed and is to be indicated in the top section of the Standard Disclosure Form. Send this form in its ORIGINAL format to the insurance company/adjuster along with the 21 day intent to treat notice the day or two after the first visit and send it certified, return receipt requested to show PROOF that this was done. Send copy of this form to Lori Worrell for recording in "Provider's file"“Provider” is to also keep a copy “Provider” files. This form is the most crucial form you will deal with because without it and the 21 day notification form filed within the 21 days with proof, the patient nor the insurer is responsible for any submission of claims on this patient. FL PIP CLAIMS ONLY.
d. “Business Associate Agreement” signed for HIPAA Requirements.
e. Copy of "Patient Privacy Notice" (copy given to each Patient).
f. “Assignment of Benefits, Release of Records & Payment Agreement” form signed by patient and “Provider”.
g. “Eligibility Form OIR-B1-1773” signed and notarized. For Florida Auto (PIP) Cases Only.
h. “Insurance Company Contact” form copy to Verify Benefits or to Obtain Authorization from Insurance Company, if “Provider” has already obtained such in advance.
i. Dates Of Service (DOS), Procedures and/ or Modalities and “Providers” Fee Schedule as requested to be billed by Lori Worrell.
j. “Attorney Letter of Protection” (LOP), signed by patient and Attorney when requested by Lori Worrell or if provider already has one in file.
k. “Provider’s” National Provider Identification Number (NPI) will be provided to Lori Worrell.
l. Rendering Providers’ NPI, if other therapists are working for “Provider.” All therapists rendering services to “Provider’s” clients /patients must sign daily documents that were created by that therapist and such therapist must also have their own NPI Number.
m. Any other Documents or Information Lori Worrell shall request for completion of filing and collection of patient claims.
n. INITIAL VISIT Requirements: All of the above signed forms and information for initial visit must be submitted to Lori Worrell by priority mail with delivery confirmation within five (5) BUSINESS DAYS from the 1st. date of patient’s first visit.
o. After the initial visit all forms may be faxed to Lori Worrell. If faxes are unreadable due to not being dark enough, not clear enough or for any other reason, priority mail will be required.
ALL INSURANCE PAYMENTS TO GO DIRECTLY TO “PROVIDER”
UPON RECEIPT OF PATIENT’S INSURANCE PAYMENT:
I, __________________________________ as “Provider” do hereby agree to Fax or US Mail within 5 BUSINESS DAYS of receipt, to Lori Worrell a copy of insurance payment and Explanation of Benefits (EOB’s) for any insurance payment, reductions, denials or other statements by insurer regarding payment and /or patient’s co-pay and deductible payments.
I understand that this information is needed for recording payments and balances due by patient and /or insurance company and for collection follow up by Lori Worrell. I also understand that there can be NO follow-up without this information.
RETURNING PATIENT VISITS:
a. Fax or US Priority Mail all copies of patient’s daily progress notes or other documentations including but not limited to copy of any updated prescription within 5 BUSINESS DAYS of receipt.
“PROVIDER” UNDERSTANDS AND AGREES:
a. “Provider” understands that every type of insurance case cannot be successfully accepted and agrees to take the advice of Lori Worrell and /or Vivian M. Mahoney in connection with any such claim that is known to be un-collectable. “Provider also understands that there is no infallible situations with insurance and hereby agrees to not hold Lori Worrell or Vivian Mahoney responsible if for whatever reason a patient’s claim is not reimbursed. This could be due to such events as patient’s benefits being exhausted, patient providing incorrect claim information or patient being sent by insurer to obtain an IME and other such events. However, “Provider” understands that these possibilities could happen less frequently with Lori Worrell’s billing services because Lori would be staying on top of these sort of issues as much as is possible.
c. “Provider” fully understands, that while Lori Worrell cannot legally and will not set, suggest or advise of fees for services, Lori Worrell will also in good faith, reserve the right to refuse to bill for services for what might be considered overcharging, over coding, coding for that which is not within “Provider’s” scope of practice and for that which is not within normal, geographical regions allowable, payable and ethical by general insurance reimbursement standards. Prior to refusal to accept, Lori Worrell or Vivian M. Mahoney will inform as to the reason for not wanting to accept the case presented by “Provider”.
d. I, ___________________________“Provider”, understands that Lori Worrell is strictly a billing service and is not required to inform me of the billing laws and rules and that it is my responsibility to know the laws, rules and requirements of billing. Therefore I understand that accepting insurance as a massage therapist is actually a business within my massage therapy business or profession, I will invest in whatever resources are necessary and available to stay current on rules and laws pertaining to insurance and heed to the advice of the billing service. I do understand that Lori Worrell and /or Vivian Mahoney are qualified to advise in most cases or when unable, will direct me to seek legal counsel.
e. I, ___________________________“Provider” agrees to promptly comply to all requests for information, settle unpaid claims due to Lori Worrell even if Lori Worrell has given required written notice of dissolution but had already performed the service, stay informed of all insurance rules and laws so that I can protect my business now and in the future from insurance company delays, denials, reductions and possible chargebacks, even though I trust that Lori Worrell will keep me apprised of any necessary and immediate information or situations that may arise.
I, ________________________________”Provider” agrees that if or when I should decide, for whatever reason, to dissolve this billing service agreement, I may do so by providing, in writing a certified, return reciept requested letter as a 14 BUSINESS DAY notice to Lori Worrell and hereby agree to compensate her for all outstanding claims or services rendered by Lori Worrell up to and including date of dismissal. I understand that claims already filed and paperwork thereafter will possibly still be in the works and I will be responsible for any outstanding amounts, if any, due on those claims.
FAILURE TO COMPLY BY EITHER PARTY:
a. If I, Lori A. Worrell, should fail to comply with any of the above criteria, “Provider” may, without repercussions, withdraw from contract with a written notification by US Certified Mail within 14 BUSINESS DAYS of Lori Worrell’s failure to comply.
Exception: “Provider” will still remain responsible for any payment balances due by “Provider” to Lori Worrell for services already rendered.
b. If I, _____________________________, “Provider” fails to comply with any of the above criteria, Lori Worrell, may without repercussions, refuse any further services, with a written notification by US Certified Mail within 14 BUSINESS DAYS from “Provider’s” failure to comply.
Exception: Lori Worrell will be responsible to return, by priority mail, with delivery confirmation all of “Provider’s” records within 14 BUSINESS DAYS of the first date of “Providers” failure to comply.
“PROVIDER“ PAYMENT INFORMATION, OBLIGATIONS & OPTIONS:
Provider is to check desired option below.
Claim:
A single patient visit represents a CLAIM, no matter which patient or what sort of case it may be.
Patient's Complete Initial File Set-up and Continued Maintenance of Patient Files is $85.00 per each new and accepted patient. This payment is due and payable upon notification to “Provider that the individual case is a valid case and has been accepted by Lori Worrell.
All cases are not accepted because of known insurers non- payment policies.
Lori Worrell will notify “Provider” upon initial communication or after consultation with Vivian Mahoney if there is any doubt as to whether or not patient’s insurance would reimburse “Provider”.
If after notification that reimbursement would be unlikely and “Provider” accepts this advice, no File Set-up Fee would apply because no file would have been prepared.
If “Provider still wants to proceed with filing the claim, for whatever reason, a full File Set-up Fee of $85.00 in addition to fee per claim date filed will apply and is non refundable.
If a “Provider” has already accepted one or more insurance cases and has not been successful and now wishes Lori Worrell to review, reprocess or follow up on these claims, a $38.00 fee will apply per each bill review prior to evaluation of such claim, whether or not a claim is refilled by Lori Worrell.
“PROVIDER” OPTIONS
OPTION 1. __________$85.00 File Set-up Fee per each new patient accepted by Lori Worrell. Plus $14.50 per claim (patient visit). Collection and communication engagements with attorneys will involve an additional fee of $10.00 per each documented written communications plus $1.00 per page will be charged if legal counsel requests copies. In most cases this fee can be directly charged by Lori Worrell to the attorney. If attorney does not reimburse Lori Worrell for these claim copies submitted on "Provider's behalf a $1.00 fee will be charged to "Provider."
Summary: Initial File Set Up Fee of $85.00 is due upon acceptance of each valid /acceptable patient case and File Set-up.
In addition $14.50 will be due per each claim (patient visit) filed and is due the week of claims submission to insurer.
Lori Worrell will invoice “Provider” by email or fax. “Provider will pay by credit card on file. * See Payment Acceptance Summary Below.
You might want to choose this option if you think you will be accepting only a few cases.
OPTION 2. ___________ $85.00 File Set-up Fee per each new patient accepted by Lori Worrell. Plus a flat monthly fee of $140.00 for any and all patient claims up to and including 20 claims, (patient visits). After the 20th claim (patient visit) is filed, a fee of $6.00 per each claim (patient visit) will prevail during that specific month. Collection and communication engagements with attorneys will involve an additional fee of $10.00 per each documented written communications plus $1.00 per page will be charged if legal counsel requests copies. This fee will be only $.50 cents with Workers' Compensation attorneys or patients thenmselves.
Summary:
Initial File Set Up Fee of $85.00 is due upon acceptance of each patient case and File Set-up.
In addition $140.00 per month is due upon acceptance of and signing of contract and on the same day of each month thereafter for up to and including the 20th claim. Once “Provider’s” total claims reaches 20 patient visits per month, claims fees will then be $6.00 per each claim for that specific month and will be due on the 28th day of each month. The fee of $6.00 per claim is for each patient visits. However this does not change the fact that an $85.00 set up fee is due for each and every accepted patient as a one- time charge.
Example: $140.00 a month covers up to 20 patient visits per month. For 21 plus patient visits during a specific month fees will be only $6.00 per visit unless the patient visits drop below 20. Should this happen the original agreement would revert back to the $140.00 per month.
Lori Worrell or Vivian Mahoney will invoice “Provider”. “Provider will pay by credit card on file. * See Payment Acceptance Summary Below.
You might want to choose this option if you think you will be accepting a high number of cases, if not, Option 1 would be your best bet..
OPTION TO CHANGE
“Provider” will be given an option to change OPTIONS at the end of each 6- month period.
PAYMENT ACCEPTANCE SUMMARY:
$85.00 Fee for Initial File Set-Up is due upon Lori Worrell’s acceptance of and notification to “Provider” that it is a viable claim. Additional fees for claims (patient visits) are due and payable the week of submission to insurer on Option 1 and on the 28th day of each month for Option 2.
REPEATING:
A single patient visit represents a CLAIM, no matter which patient or what sort of case it may be.
· Claims will NOT be filed if Lori Worrell is certain that provider will not be reimbursed for the type of claim submitted to Lori Worrell. “Provider” will be notified of such a decision.
· There are no charges for Initial File Set- up if the claim is not actually filed, EXCEPT for the conditions described in the following paragraph.
- If a “Provider” has already accepted one or more insurance cases and has not been successful and now wishes Lori Worrell or Vivian M. Mahoney to review, reprocess or follow up on these claims then a $38.00 fee will apply per each bill review and consultation, whether or not a claim is refilled by Lori Worrell and is due prior to evaluation of claim.
HOW PAYMENTS FOR BILLING SERVICES WILL BE ACCEPTED
VISA, MasterCard, Discover and American Express Credit Cards are accepted.
Until further notice all payments will be made by credit card and will be held on file and processed through Vivian M. Mahoney’s First Data Credit Card Processing Company. Automated Receipts will be emailed to “Provider” through the credit card processing system upon credit card being processed and accepted by the system. (Vivian’s references provided upon request). Vivian Mahoney will then immediately process payment to Lori Worrell for invoiced services provided to "Provider".
Providers Name: _____________________________________
Company Name: ________________________________________
Address Street: _________________________________________
City: _______________________________ State____ Zip_______
Phone Number: ______________________________________
Fax Number: ________________________________________
Email: _____________________________________________
SS#:____________________________________ Needed for Billing Claims or
TIN# or EIN# _____________________________Needed for Billing Claims
Upon Lori Worrell’s Acceptance of Contract Agreement “Provider” will call Vivian M. Mahoney or vise versa to provide credit card information.
Phone: Home/ Office: 865-436-3573 or Cell Phone: 865-850-3195
Provider understands HIPAA Privacy Rules will be followed and that credit card and all patient identifiable information is kept strictly confidential and in a safe locked location.
ADDITIONAL NOTES ABOUT FEE SPLITTING PAYMENT WHEN REIMBURSED
While Lori Worrell and Vivian Mahoney realizes that there are billing services available who may charge percentages of claims filed, it is hereby advised that Lori Worrell does not participate in fee splitting, which is considered an illegal arrangement.
Lori Worrell does not agree to provide services on a pay as reimbursed to “Provider” plan as some in the industry do. Reason for this is because there were many massage therapists in the past who either did not pay when they received reimbursement or who would not keep billing service notified of payments received nor non-payments so that billing service could perform proper follow up. Lori Worrell agrees to keep the “Provider” current on types of claims that will and will not reimburse “Provider” in order to reduce unpaid submitted claims.
MASSAGE INSURANCE RELATED UPDATES TIPS AND NEWS:
By signing this contract I understand that I will be placed on Vivian M. Mahoney’s ‘Massage Insurance Update” list and will remain informed of any insurance or health related information, laws and rules and changes with regards to coding, fees and other important information that may benefit my massage practice. I understand I may unsubscribe at anytime.
“Provider’s” Signature: ____________________________________ Date: ________________
Lori Worrell’s Signature: _____________________________ Date: ________________
DISCLAIMER:
Lori Worrell or Vivian M. Mahoney are not and do not pretend to be Attorneys, CPAs or Accountants. Therefore you, the “Provider” agrees by signature herein to hold Lori A. Worrell &/ or Vivian M. Mahoney harmless for any causes in connection to insurer delay, denial reduction or refusal of reimbursement on said claims.
Lori Worrell and /or Vivian M. Mahoney refuses to do anything considered illegal, immoral or underhanded while providing billing services for “Provider” and at the same time will do all that is necessary to protect the “Provider” from any illegal, immoral or underhanded practices.
Both Lori Worrell and Vivian Mahoney promise to do everything in their power to see to it that claims are paid and /or to notify the “Provider” that they will not be reimbursed and to therefore recommend that the case not be accepted for insurance reimbursement.
I hereby attest to the fact that have read and understand the above Disclaimer:
“Provider” _________________________________ Date: ________________
Advanced Massage Insurance Billing
Lori Ann Worrell
Email: loriannworrell@aol.com
P. O. Box 3592 Lantana, FL 33465
Present Mailing Address:
Phone: 561-502-2048
Instead of FAXING please scan and email to: loriannworrell@aol.com or FAX to Vivian at 1-888-822-5006
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