Outside Biller: Evaluating services to find the best fit – Part 2

Outside Biller: Evaluating services to find the best fit – Part 2

Last time, in Part 1 of the series, I discussed the choice of outsourcing vs. doing your own billing.  That decision may be the cornerstone of your practice’s success.

How do you choose from the hundreds of outside biller services?  

Many of the inquiry calls I receive fall into one of two scenarios.

In one, a clinician calls and only asks what I charge. While it is important to have a budget, price is only one of many important considerations. Remember – a biller has the power to make your business succeed or fail. With that in mind, choosing the lowest bidder may be a risky move.

Alternatively, therapists tend to be friendly people and use emotion to guide decisions. The second type of caller generally chats with me about billing, hoping to feel comfortable and establish a relationship. Being friendly with your biller is nice and will definitely help to build trust. 

Trust is important – this person will be handling your money! But aside from the trust factor, a strong personal relationship does not guarantee billing competence.

I suspect the main reason I don’t get more interview questions is because clinicians don’t know what to ask a potential biller, aside from the cost. After all, if you knew about billing, would you need an outside service? 

So, my goal here is to help you to identify critical factors in the choice of the right company or individual for YOU.*

*Note: I understand some clinicians consider the venture capital firms (Alma, Headway, etc), to be “billing services.”  I’m not going to discuss these options here. Their offerings differ enough from billing services to make side-by-side comparisons impossible. 

Other reasons include the future impact these firms might have on private practice. I am currently researching this topic and possibly will write about it at another time.


5 Questions to ask a billing service when looking to outsource


How much is this gonna cost?

This first question really should be the last!
There’s an enormous variety of services and packages out there.

The price quoted will depend on multiple factors.

Let’s take a look.
  • Their technology expenses
  • Labor costs
    • US employees only?
    • Virtual, in-office, or hybrid?
    • Outsourcing offshore? To what extent?
    • Employee level of expertise (certifications & experience? or relatively new?)
  • Specialty of the billing company
    • Billers typically charge more for certain specialties than others.
      • Mental health billers will submit many more claims but receive a much lower reimbursement per claim than surgical billers, for instance.
      • A billing company offering multiple specialties may have a different price structure than a biller who only handles mental health.
  • Geography and Compliance
    • What is considered a “reasonable” fee to charge where the biller is located?
    • What is the average fee where you are located?
    • The prevalence of virtual work means that your biller might not be local to you.
      • What is the average fee where the remote biller is located?
      • If there is a discrepancy, the costs in both areas should be considered.
    • Check your local laws: 
      • Some states have banned percentage-based billing fee structures. Others only prohibit it for Medicaid funds but it’s ok for commercial policies.
        • Do your research. This article is a good place to begin that process.
        • Choosing a biller that operates against the laws of your state could jeopardize YOUR license! 
      • Does your state require certification/licensing of billing companies? 
        • For instance, some states (such as Arizona) require billing companies to be licensed as collection agencies.  
        • A few states even charge sales tax on billing services!
      • Does the biller understand the payers, quirks, and laws of your state/location? 
        • If not, are they willing to learn?
        • Will you need to pay for their learning curve?
      • Ask questions about their HIPAA and OIG compliance plans, activities, training, and monitoring. A reputable service that pays attention to compliance will not mind sharing this information with you.
  • Pricing arrangement: there are many ways to pay a billing service for their work!
    • Percentage
    • Hourly
    • Per project
    • Per claim or clinical encounter
    • Packages
    • Flat monthly fee
      • With or without tiers to accommodate more or fewer clinical hours in any given month?
    • Implementation fees?
    • Minimum fees?
    • Do denials and clawbacks affect what you pay your biller?
    • Add-on charges (software access; postage; electronic transactions) ?
    • Will there be any price variations that result in expenses higher than expected?
      • If yes, what factors cause the variations?
      • Are these factors under your control, or not?

When you are quoted a price – high OR low – ask about ALL services that are (or are not) included. If you intend to compare different companies/solutions on price, they need to be offering the same features, or your comparison will be meaningless. 


What software does the outsourced billing company use?

use yours or the billers softwareWill the billing company use their platform, or yours?

If they use yours:

Is it an effective product for billing?

Many of the commonly-used do-it-yourself EHR systems are better for clinical applications, than for billing. (I realize that this opinion of mine might not be popular…)

If the biller uses their product:

  • Can my current EMR be integrated?
  • If no: do they have an integrated EMR / should I switch to theirs?
    • If I do, what happens to my clinical records if I change billers?
  • Does their integrated EMR handle mental health to my satisfaction?
  • Is their integrated EMR easy for me to use?

If your clinical EMR does not integrate at all with the biller of your choice:

  • Will you have access to the biller’s software? Read-only or editable?
  • Who does charge entry? Payment posting?
  • What (if any) role will the biller have in your clinical system? 
    • How does this impact what you pay for your system?

Some billers will work on any platform requested. Others will only work with programs they think will deliver the best outcome.  The right answer is what works best for both the therapist and biller – and gets you PAID!


Does the billing company offer the services you need? 

In Part 1, I introduced the concept of revenue cycle management and listed the many functions necessary to achieve profitability.

  • Does the prospective outside biller offer a suite of services closely aligned with what you need? services
  • Are add-on services possible?
  • Is it possible to decline RCM functions you do not need?
  • If you add or decline options, how does this affect your costs?
  • If you only need one or two functions, will the company accommodate this?

Clinicians who inquire about services typically are surprised when I spend significant time assessing their needs. Yes, it’s time-consuming. But having such conversations before signing a contract is the best way to ensure a good fit and a fair price. 


Does their size, structure, and account management workflow meet your needs?


A smaller outside biller can be appealing. More individualized attention!

But there is a downside. What happens if a key person is unavailable? (vacation, illness, etc).

On the other hand, a large firm might not provide you with enough personalized attention.

The only right choice is what works best for YOU!



Who will handle my practice? 

  • Just one person? 
  • A small team or department? 
  • Is it an assembly line model? (One team for each RCM function, handling all accounts.)

Who do I contact if issues arise?  

Is the owner/management responsive? Receptive to my feedback?  How much flexibility will I have to request alternative arrangements if I am dissatisfied?


Is the billing company a specialist in mental health? 

In 2023, billing for behavioral health is no longer as different from medical specialties as it used to be. But, there are still quirks that set us apart. The important question for you to ask is: how much experience has the biller had with behavioral health?

Mental Health Team

There is absolutely NOTHING wrong with using a larger, multi-specialty billing service. Many billers I respect are the owners of larger firms. I wouldn’t be the biller I am today if I hadn’t had those colleagues to learn from. 

Whether your RCM company bills only for mental health will be a matter of personal preference. Presumably, after you have taken into account all other considerations.


In the end, what matters most is that whoever you hire gets the vast majority of your claims PAID! 

Want to try it on your own? Join me for Part 3 – How to be Successful doing your own billing.

Hire A Biller? Which way to go?! – Part 1 of 4

Hire A Biller? Which way to go?! – Part 1 of 4

I’m often asked whether it’s better for therapists to hire a biller or to do it themselves. 

Happy to help with this and other related questions!

But…there is a problem…  Therapists tend to expect a definitive yes or no answer. 

I find this strange. As a therapist, would you tell your client what they should do? 

Yet, clinicians seem to expect that my advice regarding whether to hire a biller is a one size fits all proposition. 

Sorry. It’s just … not that simple. 

In fact, there is so much complexity in answering this question that I am going to take FOUR blogs to address it! 

Part 1 – Hire a biller or do my own? Overview.
Part 2 – Outside biller: evaluating services to find the best fit.
Part 3 – How to be successful doing your own billing.
Part 4 – How to evaluate billing software. This is critical regardless of who the biller is. 

Should I hire a biller?

Which resource do you have more of – time or money?  Let’s look at both.


Billing takes time! There’s no getting around it.

Claim submission is no longer time-consuming, thanks to online EMR/practice management (PM) platforms.  But if by “billing” you are thinking of claims submission, that alone won’t make your practice profitable. What is needed for profitability is revenue cycle management (RCM).

Say what?

RCM is the fancy industry term that describes ALL the activities needed to ensure a practice’s profitability: 

    • Obtaining correct, complete intake information (including insurance cards)
    • Eligibility/benefit verification
    • Claims submission
    • Review rejected claims, correct, and resubmit
    • Posting of paid, denied, and deductible claims
    • Dispute/appeal denials or underpayments, and follow up – often repeatedly! 
    • Follow up on claims that disappear/stay pending too long
    • Reconcile remittances with banking
    • Challenge clawbacks
    • Manage patient balances, which can include multiple tasks:
      • Invoicing
      • Charging credit cards
      • Out of network superbills
      • Discussing balances / deductibles in a therapeutic manner, developing payment plans as needed.
    • Ensure provider enrollment stays current, correct, and matches claim submission 
    • Stay on top of the numerous payer rules that affect your practice
    • ….REPEAT!

And that’s in addition to doing your clinical notes. Because you can not submit claims until those notes are done!!  If you are – STOP! NOW! Talk to me if you need to know why.


Exhausted yet?


Hire a biller

It’s more manageable than it sounds.
However, you must have the time and the right ingredients.




In my experience, these are:

It may not be the…

  • cheapest product
  • one “everyone” uses.
  • most visually appealing

It’s the one that has the best mix of features, usability, support, and affordability FOR YOU. There is no “perfect” program out there!

  • Organization / setting up a good workflow and sticking to it
  • Patience – LOTS of patience!
  • Frustration tolerance
  • Attention to detail
  • An interest in problem-solving
  • Compartmentalize your emotions 
    • Meaning?  YES, insurance is awful, a mess, etc. I’m sure I’ve used every adjective and four-letter word you are thinking of right now! (and probably more…)
    • But if you’re going to deal with it, you will be successful IF -and only IF- you can learn to put those attitudes and emotions to the side while you concentrate on getting the job done. Afterward…go to the gym and hit a punching bag!  (Or don’t take insurance).
  • Willingness to learn new skills
  • patience when it comes to billingInsurance basics
  • Technology
  • You don’t need advanced math, but are you willing to deal with numbers?
  • …and did I mention patience?

Good billing services, virtual assistants, or W2 employees are not cheap.  I understand that it can be tempting to go for the cheapest solution. But too often, I’ve had desperate clinicians interviewing me on the phone, in tears because a bad biller has cost them thousands, even tens of thousands of dollars. They ask how much of that back revenue I can collect for them. The answer is dependent on the payers, the specific scenarios, and most importantly the age of the claims, but is usually only a fraction of what they are owed, possibly less than 50%. Is saving money on a biller worth losing that kind of revenue?  In the end, do you come out ahead?

Finding the right person – or team – is critical!  

This is your income! 

If the person you hire does not do a good job, how will you pay the rent – or YOURSELF? 

So how much does it cost?

Whichever way you go, it’s significant. It may even be the single most expensive item in your operating budget.  But if the biller you hire collects 95% or more of the income that you have worked so hard for, then isn’t it worth it?  (95% is a realistic expectation, in my experience.)

What are your choices?


Part-time vs full-time? How much above minimum wage are you able to pay? Consider taxes, health insurance, and other benefits (vacations/paid time off, retirement-401K, productivity bonuses, etc). Plus the cost of payroll and related services. Also, consider that you will need time and energy to train and manage an employee.  Can you provide working conditions that will attract good talent?

If you are considering a 1099 contractor instead of an employee, can you be sure you meet the IRS classification for contractors vs an employee? If you mis-classify an employee as a contractor, you could be liable for hefty tax penalties.

Either way, are you able to monitor effectively without micro-managing? How will you provide needed training or supervision?


Does the service charge a percentage* of your income?  Other possible ways billers can charge: per transaction, per hour, flat fee per month.

*Percentage-based billing is illegal in some states, either in full or in part. Make sure you do your homework as to YOUR state’s law.

Sometimes the fees adjust up or down depending on collections or volume, sometimes not. 

Are there minimum fees? Implementation fees?

Are you paying additional costs, such as software, statement, or electronic transaction charges?

Be sure to ask which of the above RCM functions are (or are not) included. You can’t compare two different solutions on price unless they both offer all the same services.

And these are strictly the cost considerations…In Part 2 I will offer concrete guidance on things you need to contemplate before signing a contract with an outsourced biller or billing service. 

Even if you are outsourcing, you still have to monitor performance!  For instance, how will you know if your biller – whether contractor, in-house employee, or outside service – is collecting close to 100% of all revenue you have earned? You will have to identify a way to determine if money is being left on the table.

“Time vs. Money”

Is a spectrum, only a place to start evaluating your practice’s needs.  “In-house” and “outsource”both require time AND money

  • Doing your own billing: you have less time but make more money. 
  • Hiring an employee, virtual assistant, or a billing service typically allows you to achieve more time for yourself.
    (Or the ability to see more clients with that extra time.) But, there are more expenses that will reduce your income.

What’s Next?

Evaluate where you are in your private practice journey:

Where are you headed?
What does your ideal practice look like?
What is your ultimate goal for your practice?

These are personal questions that can’t be answered in a blog.  I highly recommend that you take the time to sit down and answer these questions realistically in order to make the best possible decision for your practice – your business!


When making your decision, consider what you want from your practice.

Where you are in your life and career will definitely play a role.

  • Just starting your practice? Mid-career? Headed toward retirement in a few years?
  • Do you have additional sources of income?
  • Number of client sessions per week do you want to do? 
  • How many hours per week do you need for documentation and clinical administration?
    (notes, treatment plan collaboration with other professionals, continuing education)
  • How many hours per week can you realistically devote to non-clinical administrative tasks?
    Consider: scheduling; billing/revenue cycle management; marketing; managing requests for new services; returning calls

What are you good at in terms of the billing world?

  • If you’ve done billing in the past or are doing it now, what do you struggle with? 
  • Can you learn to improve – and do you WANT to?
  • Based on the clinical hours you are going to work, what is your income likely to be?
    • Can you afford the services you want and still make an acceptable income?
    • If you cannot, then what is the best compromise until your income improves?
  • What’s your level of comfort with technology?

Finally, consider the ingredients I mentioned above that contribute to success in billing. 

  • There’s no shame if these don’t describe you – most of us didn’t earn clinical degrees with the goal of becoming a biller. (I’m an aberration!)
  • Keep in mind that what works for your colleagues, may not work for you.
  • It’s important to be realistic, whichever way you decide. 


In-house vs outsource isn’t so simple after all.  


I’ve barely scratched the surface – which is why there are several more parts to this blog on the way. I hope you’ll join me as I continue helping you decide what’s right for you.

Part 2: Outside biller: Evaluating services to find the best fit.

So, you’ve decided to hire an outside billing service. What now? How do you find the service that’s right for you? I’ll have lots of tips, so don’t miss Part 2.

3 EASY Steps – How to Collect from Medicare Clients

3 EASY Steps – How to Collect from Medicare Clients

“In many ways, Medicare is much easier than private insurance, but it has a language all its own.” I say this a lot.
Once you’re initiated into the Mysteries of Medicare, you’ll find that one HUGE advantage is almost NO time spent in lengthy Verifications of Benefits. Here we will discuss 3 Easy Steps – How to Collect from Medicare Clients.

Time IS money – and if you spend an hour or two each week verifying benefits, well, now you can use those hours to take two Medicare clients and make money instead!  Time is Money!

Medicare benefits are ALL THE SAME… As long as it’s Original Medicare!

In this blog, I’m going to cover Original Medicare, which in 2023 is now only about 50% of Medicare enrollees.

Medicare Advantage is seriously COMPLICATED – because it’s also private insurance! Learn how to spot -and AVOID – the pitfalls that result in no payment by registering for the upcoming webinar…

Therapists: Medicare Demystified! on Friday, May 19, 2023, at 10 am Pacific time.





Billing Medicare PART B – Collecting from Medicare Clients


Verify ELIGIBILITY – Step 1!

Someone calls you and says, “I have Medicare.”  Your Billing Buddy’s first piece of advice is…

Just because they have Medicare, does NOT mean you will BILL Medicare!
(Remember –  what I said about 50% of Medicare enrollees having Medicare “Advantage.”)
Fortunately, there is a way to verify with 100% accuracy whether a client is enrolled in Medicare Advantage (also known as “Medicare Part C”). Try getting 100% accurate results with private insurance…!!

Here are a few automated ways to get Original Medicare eligibility:
  • Medicare’s telephone IVR (interactive voice response) system
  • Portal operated by your Medicare contractor
  • Your clearinghouse/software vendor

For the portal or software option, enter your client’s demographic data and Medicare # (NO DASHES OR SPACES), and that’s it!
What you get back will vary slightly in output format depending on the electronic intermediary used, but watch for any of these terms:

  • Medicare Part C
  • HMO Medicare Risk
  • Capitated
  • Medicare Advantage / Group Medicare Advantage
  • Medicare + Choice (an old name for Medicare Advantage)
  • Medicare Private FFS – (means Fee for Service – not the Internet/text acronym. Despite it being VERY appropriate…)
  • The name of a private insurer

If present, these will appear close to the top of the eligibility return.

Once you have this information, you only need to scan for the presence or absence of these letters:
QMB (Qualified Medicare Beneficiary), which means no matter what, you cannot collect any money from the client. The QMB designation will appear next to any other insurance policies listed, also near the top of your results.

In addition, you can check the accumulations toward the Part B deductible if it’s near the beginning of the year. All Medicare eligibility summaries will contain this information – unless the client is QMB.

And be sure to check the coordination of benefits (filing order). Medicare CAN be secondary – it’s not always primary.
Getting eligibility errors? There are a few common scenarios. If you join us on March 10th for the Therapists: Medicare Demystified! webinar, you will find out what these might be and how to troubleshoot.


Supplement or Secondary? – Step 2!

Ask your client if they have one. Be sure to get ALL the client’s insurance cards (if you can). Most of the time Medicare will forward to the next plan – but not always.  In Medicare-ese, when Medicare forwards the claim, it’s called a “crossover.”

Pro tip: Check your Medicare remittance. It will say at the bottom of the claim line:

MA18  ALERT: The claim information is also being forwarded to the patient’s supplemental insurer:
Send any questions regarding supplemental benefits to them. 

Didn’t get the card or info about the plan Medicare forwarded to?   It happens.
Here’s my tried-and-true workaround.

I set the patient bill date ahead about 30 days. If money comes in from another payer before that time, great! I now know what the next policy is, and I add that information off the EOB into my billing program.

If there is no payment after 30 days, do one (or both) of two things:

  • Bill the patient or the power of attorney/guardian. It’s surprising how often a bill conjures up an insurance card that didn’t exist at the time of scheduling the appointment.
  • Call the payer referenced on the MA18 line – give them the client’s name, DOB, and Medicare #. They may or may not be able to give you eligibility information. The payer may also have a portal that is configured to accept the Medicare number.

If you can get the correct policy information, send a paper claim with a copy of the Medicare EOB/ERA (electronic remittance advice) attached.

What to Collect? Step 3!

Medicare’s Part B benefits are very simple.

Each year the federal government announces the deductible amount (it is $226 in 2023), and then Medicare reimburses 80% of the allowable amount.

Decision Tree:
If the client has no other insurance…collect the deductible or 20% as indicated on the remittance. Once you know the allowable amount for each code, you can collect it at the time of service.

If there is another payer, wait for the secondary claim to adjudicate and then collect whatever is left over – if anything. In the webinar on March 10th, I’ll present some seriously effective shortcuts where you can find out EXACTLY what certain policies will pay – NO VERIFICATION NEEDED.

If you are a “nonparticipating” provider, you may also collect the 15% “limiting charge.”

If the secondary payer is Medicaid – BEWARE!

Federal law prohibits the collection of Medicare deductibles & coinsurance from QMBs, but not all Medicaid enrollees qualify for the QMB program.

If your client is not QMB but IS enrolled in Medicaid, you MUST check state Medicaid law before collecting.

MOST states forbid collection from Medicaid enrollees.
 A few allow collection only for procedures the state Medicaid program does not cover.
When in doubt – call your state for clarification or do not collect money from a Medicaid-enrolled client.

Then there are times that Medicaid “covers,” but doesn’t actually pay!
Let’s say the Medicare allowable for the code billed is $115. For the same code, your state’s Medicaid program allows $85.
Medicare will pay 80% (which is $92, roughly, because of the sequester).
Since $92 is higher than the state’s allowance of $85, the state will conclude, when the claim reaches them, that you have been paid in full.

In this instance you will have to write off $23, you cannot collect it from the client.

These are not considered a “routine waiver” of patient responsibility, because there is no patient responsibility. The same is true even if you choose not to be a provider for Medicaid. Medicaid would cover the service if you chose to participate.

If you would like to schedule a consultation, please contact me today.  I am here to help!

And that, my friends, is ALL there is to it.
Until next time,
AKA “Your Billing Buddy”

Click here now to Register
Therapists: Medicare Demystified!
on Friday, May 19, 2023, at 10 am Pacific time.


Find out how to bill Medicare for telehealth after the end of the COVID Public Health Emergency!
Need to learn how to read the Medicare fee schedule?
What is covered by Medicare, what should be in your records, and what do you do if you get audited?


I Don’t Want to Enroll in Medicare!!!

I Don’t Want to Enroll in Medicare!!!


Do I have to enroll in Medicare?

In true Medicare doublespeak … The answer is both YES – and NO.  But I Don’t Want to Enroll in Medicare!

There are three categories of Medicare provider enrollment.  The government expects all Medicare-eligible clinicians to make a choice and enroll accordingly.

What they DON’T want, is for clinicians to refrain from choosing. The government expects all Medicare-eligible clinicians to enroll in Medicare or opt-out. There can be negative consequences to staying outside the system.  

Attention: Counselors and Marriage-Family Therapists,  beginning in 2024 this will include YOU, as well!

For the uninitiated, Medicare seems designed to frustrate, with all its acronyms, lingo, and peculiarities. But it doesn’t have to be this way. 

Upcoming Webinar!       Therapists: Medicare Demystified! 

Your Billing Buddy will be your guide to the next upcoming webinar Friday, March 10th at 10 am  Pacific / 1 pm Eastern.

The 3 provider enrollment categories

Participating – There is no “credentialing” in Medicare. Compared to a private insurer, it’s a relatively
straightforward and short process.   (Keyword here being relatively…!)

To enroll on paper, you file the appropriate forms:   CMSTherapists: Medicare Demystified!
855I (for individuals)
855B (groups)
855R (individual group members reassigning benefits)
588 (electronic funds transfer is required)
460 (participation agreement) 


Or, you complete the same information on PECOS – Medicare’s online enrollment system.* 

*This June, CMS will be launching a redesign of PECOS. If you plan to enroll, I suggest enrolling by the end of April – or wait to start once the upgrade is complete.

Medicare’s enrollment process takes 30-45 days once your enrollment application is deemed complete. If something is missing or incomplete, you will receive a letter and are given 30 days to resolve the deficiency

There may also be a site visit. If you work mostly remotely, or in an office owned by another entity, call the Provider Enrollment department at your MAC (Medicare Administrative Contractor) to ask how to proceed. Site visits are a negative consequence of past fraud. 

Medicare needs to ensure you are a legitimate business. 

Once enrolled, your Medicare provider number will be made retroactive 30 days from the date your application was received. 

To bill, hook your billing system up to send claims electronically…and off you go! (Medicare does not accept paper claims except in special circumstances). 

Participating clinicians are required to:
  • Submit claims for clients.
  • Accept the Medicare allowable rate as payment in full. 
  • Only collect deductible/coinsurance from your client. (No superbills)

Non-Participating – It’s not all that different from Participating, but with a few key features.

During enrollment, you will NOT sign the participation agreement. (CMS 460). The lack of this form is what enrolls you as non-par. Otherwise, the enrollment process is identical.

Non-participating providers are allowed to charge more. Specifically, in a Medicare
mathematical sleight of hand, 10% more. Here’s ho
w it works. When Medicare processes your claim, they will allow 95% of the amount paid to participating providers. The non-participating clinician is then permitted to add 15%, with the total net gain, therefore, being 10%.  The 15% is what is referred to as the “limiting charge” – the amount that a non-par provider can add on top of what Medicare allows.*
*Some states, such as New York, restrict the limiting charge. Contact a licensed healthcare attorney in your state.

You MUST file the claims for your client. However, you do NOT have to accept the assignment. (Accepting assignment = Medicare pays you). You are allowed to collect in full at the time of service: the Medicare allowed amount + the limiting charge. Upon receipt of a non-assigned claim, Medicare will reimburse your client directly.

Unlike with a commercial or a Medicare Advantage plan, the benefits to your client are NOT reduced if you are non-participating.  However, your client’s supplement or secondary plan may not reimburse them for the limiting charge.

Still want absolutely NOTHING to do with Medicare?   

Then you need to Opt-Out!  Opting out is the third enrollment category.

Opting out is the simplest of all. There is a short form you file to Medicare, called an affidavit. Each Medicare contractor has one available for download on their website.

Opting out is an all-or-nothing proposition: It applies to all Medicare beneficiaries. If you currently have clients with Medicare, they will lose their benefits too – not just your new clients. Want to keep your current Medicare clients, just don’t want any more?  

Tip: close your practice to new clients rather than opt out.  

Opting out covers all services/procedures covered by Medicare.
Opting out puts your NPI on a publicly searchable list and applies to ALL practice locations. So know this…

If you’re out – YOU’RE OUT!

You cannot be opted out in your private practice but then accept Medicare clients at a group or facility.

What if I opt out but want to re-enroll in the future?

You can! There is never a barrier to changing your status, although naturally, there are a few rules… (hey, it’s Medicare!)

  • For clinicians who are in their first opt-out cycle, there is a one-time “buyer’s remorse,” or Early Termination. You can cancel your opt-out enrollment within the first 90 days of your opt-out date. This is not available, ever again. 
  • Be mindful of when your two-year cycle ends. You can only re-enroll at the end of the two years. You must re-enroll no later than 30 days before the start of the next two-year cycle.

Note for clinicians who prescribe medication:   As an opt-out provider, the drugs you prescribe will ONLY be covered by Medicare if you stay enrolled with your privileges restricted to order, certify, & prescribe. This is an option. 

The Private Contract

Each Medicare contractor has one of these available on their website as well. My advice is to download it, and don’t modify it except to cut & paste the verbiage onto your letterhead.

It’s important for you to know – What does it say? 

Your Billing Buddy

A lot of things, some of which are obvious enough that I do not need to rehash them. The main points are the client,,,

  • agrees to pay & agrees not to file for reimbursement.
  • understands Medicare, Medicare Advantage, and/or supplement plans will not pay. 
  • understands Medicare limits on charges do not apply.
  • understands that the services could be covered by Medicare, if obtained from a provider who had not opted out. 
  • acknowledges this agreement is voluntary. 

Do not take what’s written here as everything you need, if you want to opt-out. There is more to learn. Go to a Medicare contractor’s website to download their form – or attend the March 10 webinar!

Opt-out private contracts MUST be in writing and kept on file in your paper chart or EMR. As with anything else, if it isn’t documented – it didn’t happen. 

Can I use a Good Faith Estimate instead?  

NO.  “Good faith estimates” do not apply to Medicare clients. 

What happens if I stay unenrolled?

They don’t examine lists of licensed professionals and compare them against enrollment databases. 

All it takes is one Medicare client who pays you, obtains a superbill, and then files for reimbursement. You’ll receive an extremely frightening letter. 

The letter will state:

Medicare guidelines outlined in Section 1848(g)(4) of the Social Security Act, require the physician or supplier to file a claim on the beneficiary’s behalf for service(s) rendered to a Medicare beneficiary that may be covered.  …  Physicians … who fail to submit a claim or who impose a charge for completing the claim can be subject to sanctions and/or monetary penalties.


If you’re unaffiliated with Medicare and you’ve received the above letter, choose an enrollment category and get onboard. They will not prosecute you for a first offense, IF you take prompt action. Enrolling in one of the above categories will demonstrate your compliance going forward.   

Warning: You may be required to refund fees collected from your client(s) for sessions that didn’t follow Medicare’s rules. 

Where is this written?   LEGALESE – click at your own peril!


Medicare IS manageable – But you don’t have to go it alone! 

Learn all the secrets to working confidently with Medicare, without hassles, and getting paid:

Therapists: Medicare Demystified!

Friday, March 10th
10 am Pacific / 1 pm Eastern


Until next time, Your Billing Buddy is always here if you need help!

Those Darn Deductibles – Part 2 – The Questions You Need to have Answered, but were Afraid to Ask.

Those Darn Deductibles – Part 2 – The Questions You Need to have Answered, but were Afraid to Ask.

Hello! It’s me again, Susan. Your Billing Buddy!

Last time we talked about the clocks turning over to the New Year and Insurance deductibles, copays, and coinsurance starting all over again on January 1st.   If you didn’t get a chance to read it, check it out here. Those Darn Deductibles – Part 1

How to maintain your income in the New Year!

Ok, onward!  Let’s dive into more detail here in part 2 – The Questions You Need to Have Answered, but Were Afraid to Ask

In this blog, I discuss being in-network and what you can do…and can NOT do.  One question clinicians rarely ask me is:

If I’m in the network.  Am I allowed to collect my full contracted rate ahead of the claims being submitted/adjudicated, because I know there’s a deductible?

I’ve never seen this question directly addressed in a provider contract or manual. 

However, in-network contracts/manuals say the in-network provider should collect deductibles and copay/coinsurance, and no more. But these documents never specify when you can collect them. I think that’s a critical point.

So, my answer is always

“If it’s not explicitly forbidden, then it’s allowed.”

But…  🠟 You are on shaky ground here!


Well, the most obvious reason is that the client may want to wait until the claim goes through. And if the client brings it to the insurance company’s attention, even innocently (as opposed to complaining), I’ve known payers to slap some wrists. 



Here are a few common examples:

The client or their employer may have set up a Health Savings or similar fund that will pay the deductible – and sometimes that money is distributed by the insurer. No claim = no reimbursement from the fund, and the client meanwhile is being charged out of pocket.

Or, perhaps a family member had or will be having an expensive procedure or ongoing medical condition that will take care of the deductible quickly. Family members help to satisfy the family deductible and this can help your client. (Keep reading for more information on how family deductibles work).

Let’s say the client has been meeting with you for several weeks now and thinks their deductible is almost met. Then they need another, more expensive, medical procedure. But the hospital or doctor’s office verifies their benefits ahead of time and tells them nothing has been applied to the deductible. You’ve collected – but not filed. And the client calls the insurer for more information. Not to complain about you, just to get more information. And now the payer knows. 


It’s all in the timing

Collecting too far ahead of filing can become a relationship and/or PR issue. 

There best way to avoid problems if you plan to collect deductible amounts before filing a claim, and it is something therapists specialize in: Communication.

I do believe it’s fine to collect at the time of service in January or whenever the client still has a significant amount to meet toward their deductible, even before filing claims.

But…take a few simple steps to protect yourself and be ethical.
  1. Make the time of service collection an official part of your practice policy.
    Put it in writing for new patients to sign as part of the intake. For existing patients, tell them you are updating your policies for the New Year. 
  2. Tell the client exactly how much they will owe.
    What are the contract rates for 30, 45, and 60-minute visits? Family therapy?  Given the No Surprises Act, this is a MUST to know what the cost is and make sure your client knows.  If you don’t know, find out! 
  3. File the claim at the same time you collect the deductible amount.
    You’ve collected the money, so there’s no point in waiting to file.
  4. If an overpayment occurs, identify it and refund PROMPTLY!
    It is ok if the
    client chooses to apply the overpayment forward to upcoming visits instead of a refund, but don’t assume that’s what they’ll want. Ask. Your client will appreciate being given the option. 
Most clients who have high deductibles will understand collecting at the time of service and filing claims at the same time, especially if it’s framed as your standard policy.

For new clients, be sure to notify them before the first appointment (after verifying their benefits). Explain that they have a high deductible, the cost of your service when applied to the deductible and that your policy is to collect it at the session. 

It’s better to let the client decide in advance to go somewhere else, than work for free or risk a payer complaint that might backfire on you. 

Then there are social media. It’s easy for clients to complain online. It’s not just Yelp or Google. Ever been to Healthgrades.com? Insurance payers look at what’s written there. And because of HIPAA, you should NEVER post your side of the story online. It doesn’t matter how valid your point of view is. 

License board complaints are free for clients to make – but can be costly, stressful, and time-consuming for you to defend.  Not to mention to potential effect it can have on your practice and you!

What happens if I get pushback from clients?

Here is one compromise suggestion:

After verifying that the client has a deductible with nothing applied to it, submit your first claim. Only one. Wait for the claim to come back. If it’s filed electronically and applied to the deductible, the turnaround can be as little as 3-7 days. 

Schedule the second appointment far enough ahead so that you can get a response from the insurance company beforehand. (IF CLINICALLY APPROPRIATE). 

At the time of the second appointment, bring it up. Do not expect that the client will have read their Explanation of Benefits. 

“[client name], as we discussed, you have a deductible. I filed your last session to your insurance provider and this is how they responded. The balance owed for your last session is $x, and today will most likely be $y. How would you like to pay today?”  Note: It is important to choose your words here so that they don’t assume they have the option to pay.  Make sure to use the word HOW and not CAN you pay.

If necessary, show a copy of the EOB received from insurance.

You repeat your expectation their balances must be addressed before further services can be obtained. You are modeling three things here:

  1. Therapy – and your expertise – is valuable. 
  2. If the client is going to be fully engaged in therapy, they must make a financial and emotional investment into the process.
  3. It is not ok to let a balance build up.

Am I allowed to hold claims and hope the deductible gets met elsewhere?

Again, this is something contracts and provider manuals are silent on. There’s no official reason why you can’t, but it can be risky.

Here is why:
  1. Timely filing might be as short as 90 days. Can a 4-figure deductible realistically be met by then?    Especially if other providers might be doing the same thing.
  2. The client will accumulate a huge balance by the time you finally file the claims. If you collect during that period but hold the claims, you fall into the traps discussed above. And if you do not collect…THIS IS JUST NOT ACCEPTABLE!
  3. What if you lose track of filing? You won’t have any grounds to appeal an untimely claim successfully. If you are in-network, then contractually you won’t be able to charge the client anything. If the insurance payer becomes aware of it, you will be ordered to refund money collected where claims were eventually filed untimely.  YES, REALLY!
  4. It will require re-verification of deductible status, often repeatedly. You may not want to spend the time doing this!

How do family deductibles work?

Earlier, I mentioned family deductibles. People are often confused about how these work. When a claim is received for family member A and applied to A’s deductible, the same amount is also credited to the family deductible (if the plan has one).

So, if your client has a plan with both an individual and a family deductible, the rule is that whichever deductible is satisfied first, the insurance policy will then begin to pay. 

I’m so confused!!

This is complicated. You’re a therapist, not a biller!  So let me help you understand.

Here’s an example: 

Your client is the employee, “Sarah.” Her policy has a $2800 individual and a $5600 family deductible. Sounds high? Happens all the time. 

Sarah’s husband, “Frank,” has cancer and is undergoing radiation. You’d better believe those radiation treatments and the associated drugs are expensive! 

When you check Sarah’s benefits, it shows she’s met none of that $2800 deductible. But what’s not well-known is to look at the FAMILY deductible too. Maybe it shows as almost met.

How can that happen, if Sarah hasn’t had any claims this year?

No, she hasn’t…but Frank certainly has. And every claim of Frank’s that gets applied to his $2800 deductible, also gets applied to the $5600 family deductible.

Look at it another way. Frank goes to the oncologist and his bill is $500, applied to his $2800 deductible. Now he only has $2300 left to go. But that very same $500 ALSO gets applied to the family deductible of $5600. Now there’s $5100 left to go.

Since Frank will have a lot of medical bills, all those medical bills will add up, and Sarah gets credit toward her deductible as well. 

Now that’s cool.

Now, say they also have children who have to go to the pediatrician. And maybe the kids have medications to take. While not as expensive as cancer, the costs for pediatric visits and prescriptions, which apply to the kids’ deductibles, also count toward the family joint deductible. It all adds up.

Once the family as a whole unit hits that magical $5600 – however they arrive at it – then claims for ALL family members will start to pay. 

Family deductibles mean that a “One Size Fits All” policy for your practice will not always be the best route to take. There will need to be some flexibility, to consider individual circumstances.

And that requires communication with your client about the family’s financial and medical situation. 

In the example with Sarah, if you look at her benefits and only see there is a high individual deductible and collect at the visit, without communicating with her, you might be missing key information. You could end up owing her a sizable refund, and you might end up damaging the therapeutic relationship if she wasn’t prepared to pay upfront.

This is NOT to say don’t collect. What I am saying is that each client’s circumstances are unique. And the issue is timing. You wouldn’t approach therapy with every client in the same way – so when it comes to collecting from clients, the best and first tool to use is open communication when it comes to money. 

The only rule here is that COLLECTING IS MANDATORY.  It is the how and the when that is up to your discretion.

My client is having financial problems. It’s my money, can I forgive the deductible?

Ultimately, of course, you collect for the sake of your financial well-being, BUT…and this is a big but…


You can get in serious legal trouble by waiving deductibles, copayments, and coinsurance!



Yep.  The precedents here have been set by the federal government to protect the integrity of Medicare and Medicaid; however, commercial plans usually follow the same rules. 

There have been legal cases where providers were successfully prosecuted if it was discovered they engaged in “routine” waivers of cost-share amounts.

The government’s view is that “routine” waivers of what clients owe violate the False Claims Act AND the Anti-Kickback Statute.


In English, rather than Legalese, the Anti-Kickback Statute says that healthcare professionals can’t offer or receive anything of value in exchange for referrals.

This also includes anything that may induce a client to obtain a service they might otherwise choose not to get if they had to pay their deductible, copayment, or coinsurance. 

The False Claims Act says if a provider routinely waives cost-sharing, then that means the provider is overstating their actual charge on the claim form – which is a form of insurance fraud. 


How does that work?

The therapist submits a claim for $150. A claim is a legal document. You are telling the payer that $150 is your price and without insurance, this is what the patient must pay. If you are in-network, the claim gets adjusted to your contracted amount. 

Let’s say your contracted amount is $100. If you tell the client “That’s ok, just pay me $50 and we’ll call it even” then what you are doing, legally, is committing fraud. 

Because if you’re willing to accept $50, then $50 is what should be billed. Moreover, the $50 that you have forgiven, is money that the client’s policy says they have to pay in order to obtain benefits

If you are out of network, it’s even simpler, because you are expected to collect what you bill. It doesn’t even matter what amount the insurance company says applies to the deductible; you’re out of network and can charge what you want.*

*For now, anyway…(the No Surprises Act may change this in the future).


What if the client has a financial need? Can I offer a sliding scale?

In private practice, especially one that is contracted with insurance, using a sliding scale is a potential legal minefield. I recommend avoiding it. 

When one specific client has financial needs, it is better to not waive but to set up a payment plan, as long as the payment plan is structured such that the client doesn’t dig themselves into a financial hole.

If the need is severe enough, some waivers are acceptable, but it is better to waive only some of their responsibility than 100% of it. This is important not only for your finances but also for the therapeutic process. Clients will value therapy more if they make a financial investment in it.

Before waiving some part of a client’s financial responsibility, follow the old axiom we heard repeatedly in graduate school:

When there is no documentation, it didn’t happen.

If your client has a financial need that leads to a waiver of some of what insurance says is their responsibility, then you are required to DOCUMENT the financial hardship and the reasons for the waiver. 

The government laws cited above were not intended to prevent people from getting help. The legal precedents show, repeatedly, that every situation must be individually assessed – and documented. The documentation is how you prove that the waiver is neither “routine,” nor an “inducement.”

You do want your practice to be financially healthy…right?

Do You want to stay out of court…right?

Then you have to deal with insurance (whether in or out of network), which isn’t fun for anyone…so how do you go about finding out what your patient will owe prior to their first appointment?

That’s where Verification of Benefits comes in…


Join me for a two-part webinar on January 20 and 27, 2023 where I will teach you the inside tricks.


January 20, 2023

Benefit Verification Without Pain!

January 27, 2023   

Deciphering Insurance Cards to Simplify Benefit Verification!

  • Both events start at 11 am Pacific / 2 pm Eastern and are for 2 hours.

  • Sessions are discounted over 15% during Early Bird Registration through January 16th.

  • Plus, there’s an additional discount if you register for both!


Don’t wait!


If you are looking for more help or services? Contact Your Billing Buddy!