Why is it so difficult to find correct, CURRENT information about billing and insurance topics?
Online information can be years out of date, of questionable reliability, and may not be generalizable to your problem, payer, specialty, or location. In addition, it can be sooooooooooo boring…!
After reading whatever you can find, will you be any clearer on what you need to do when you have a problem?
I’m guessing – probably not!
In this blog, I will help you with these challenges, and if you still need help, come talk to me.
Today I want to share some of the beliefs that seem to persist in mental health billing and private practice business management – despite having been repeatedly debunked.
In plain language, I will explain why these are myths and what the facts truly are. I’ll also provide suggestions to keep your practice out of trouble.
The 12 Myths
Myth #1 The client changed insurance, so I have to / can code the first session on the new insurance as 90791.
Fact: No. There is no relation between a CPT code and the client obtaining a new insurance policy. A CPT code describes what you do during a visit. In the case of 90791, it is a diagnostic interview (gathering history, understanding client goals for treatment, mental status, etc.) as opposed to a therapy session.
Clinically speaking: Why would you conduct another diagnostic interview just because the client changed plans? You will only code 90791 if that’s what you did – regardless of the insurance payer on the day of the visit. Billing ALWAYS follows your clinical documentation. No exceptions, ever.
Myth #2 Always give your client a “non-harmful” diagnosis such as Adjustment Disorder, no matter what. Or, in the form of a question to me: “What’s the best diagnosis to give a client?”
Fact: The “best” diagnosis is the one your client has! What do they qualify for in your clinical opinion? Back it up in your documentation with reference to published criteria.
That “non-harmful diagnosis” advice is a throwback to the days when there was more stigma around mental health disorders and treatment, and fewer legal protections. While there is still a stigma, I would argue that as a clinician, you are putting yourself in potential jeopardy if you try to “game” the system. And possibly even unknowingly harming your client.
If your client has a severe diagnosis, but you list Adjustment Disorder, you could be jeopardizing your client’s ability to get needed treatment covered by her insurance. If your treatment gets selected for clinical review, what do you say?
Clinical reviewer: So, why is Sally still in therapy after 3 years? Adjustment disorders are short-term.
Therapist: Well…she has severe trauma/depression/borderline personality disorder…
Clinical reviewer: Ok, so why are none of those diagnosis codes reported on claims?
That therapist doesn’t appear to have much credibility now. There’s a risk of malpractice or license complaints.
Not to mention a SLEW of record audits and possible clawbacks, since he’s now signaled to the insurance payer that he doesn’t diagnose according to published criteria.
Do you want to go through that hassle and all the stress that accompanies it?
Myth #3 I hired a clinician to work in my group practice. Since credentialing takes so long, I can bill for their sessions as if I were supervising them / incident-to.
Fact: STOP! Payers don’t allow it.
Read the definition of incident-to. It’s something else entirely.
I don’t care if a colleague did it. Maybe she got away with it…does that mean YOU will? Are you willing to risk your professional good name and possibly your license to practice?
Billing for another licensed clinician as if you were the treating provider, is fraudulent.
If that clinician is independently licensed, there’s no justification for “supervision.” (If the clinician is pre-licensed….be careful. Most private payers don’t pay for clinicians under supervision.)
Regardless of how frustrating, slow, and inefficient the credentialing process is…and it is…this isn’t a solution that is worth the risk.
Instead, try getting a single-case agreement. Or possibly the client has out-of-network benefits and is able to afford to use them.
TIP: It is EXTREMELY IMPORTANT – to make sure you plan ahead!
Credentialing and contracting can take anywhere from 30-180 days (or even longer; it depends on the payer). If you are going to make a change to your practice, do yourself a favor and plan in advance.
This is true whether you are hiring another clinician, or whether you are leaving a group to become independent, or moving to another city. Do not expect that this will be a short process. This means you will have to stockpile financial reserves in order to get through a period when fewer claims are able to be paid.
Myth #4 The client can use whichever of their insurance policies they choose or that pays the best.
Fact: Nope. It’s never up to your client, even though it does seem like it should be their choice. After all, unless they have Medicaid, the client IS paying for these benefits.
Truth: the insurance industry has set up a zillion coordination of benefits rules that determine which policies become primary, and which become secondary. It’s extremely complicated!
Trying to take responsibility for your client’s Coordination of Benefits practically guarantees denials and/or clawbacks. Don’t do for your clients what your clients need to do for themselves.
In the Store, a FREE download describes the most well-known Coordination of Benefits rules, so that you can help your client stay informed.
Myth #5 Use DSM for the diagnosis code on claims.
Fact: The DSM, for the most part, crosswalks to the ICD-10. This stands for International Classification of Diseases, version 10. It’s updated every year, on October 1st.
DSM may be the more valid or useful CLINICAL resource for mental health, but for BILLING, HIPAA mandates the use of ICD-10 codes. If you use an invalid code, your claim will reject. It will be returned to you, unprocessed.
When you choose a DSM diagnosis, be sure to use the GRAY codes that begin with a letter (usually F, for mental health). Those codes in gray are the ICD10 codes.
If you need to cross-check whether a diagnosis is acceptable for billing, go here.
Myth #6 If a claim applies to the deductible, I can resubmit it later & it will be paid.
Myth #7 Let’s all get together & boycott the insurance companies – no one signs up unless they pay $x per visit. That will force them to pay decently.
Fact: Seems only fair. Employees can unionize, right?
This is the one thing that I seriously don’t understand…and think is wrong. But I’m not a lawyer – everything I have read written by lawyers says that independent clinicians launching a boycott is currently against the law.
Aside from efforts by professional associations to level the playing field with respect to the insurance companies, there’s not much that can be done other than trying to get your own rates improved. The store has a guide to help you with that process.
Myth #8 Any amount not paid by clients is tax-deductible.
Fact: Sorry…I can’t speak to this one. Well, not definitively, anyway. But from a conversation with my own accountant this year, I’m thinking this qualifies as an urban legend.
According to my accountant, if you haven’t collected any money, then it’s not income… which means you can NOT deduct something from your taxable income when you didn’t earn the income.
That makes sense … when you put it in plain English like that. But on this one, please…talk to a qualified accountant. The IRS doesn’t have a forgiving reputation.
Myth #9 If I only file claims on paper – I’m not subject to HIPAA.
Fact: Partially true. But when you think about it, it’s a paper shield. Pun intended!
According to HIPAA, it is true that healthcare providers are ONLY subject to the Privacy provisions, and not the Security provisions, *IF* the provider does not engage in ANY electronic transactions involving Protected Health Information.
Here’s where the myth comes in:
HIPAA wasn’t talking about just CLAIMS. They meant ANY electronic transmission…of any kind.
If you EVER send a fax or send/receive an email (encrypted or otherwise), then you’ve engaged in an electronic transmission involving PHI, and..
Now you’re a “covered entity” just like everyone else!
Myth #10 I can see a client pro-bono – but I’ll file claims too, just in case the insurance pays.
Fact: If a client is truly needy, there are ethical options for treatment, pro-bono certainly being one of them.
An insurance payer has no jurisdiction to pass judgment on you if you choose to treat a client “pro-bono.” Even if you’re contracted with that payer.
But, “Pro-bono” means that no money changes hands, ever.
Adding insurance into the equation causes potential legal problems.
If you are trying to help your client meet their deductible but are not actually collecting any money, that’s the issue. On the claim, you’re saying the client owes, but then later quietly forgiving it all.
It’s considered a potential violation of either the False Claims Act or the Anti-Kickback Statute (or both). In other words – it’s illegal.
If you’d like references, contact me and I’ll be happy to send you a few.
Does anyone look good in an orange jumpsuit?
Best practice: pro-bono, and even sliding scales,
should not be used if you are also filing insurance claims for the same client.
Keep them separate.
Myth #11 I can collect money from a Medicaid client if they agree to pay.
Fact: In a small minority of states, yes, you can, IF you follow the state’s rules.
Usually, that means the client signs an agreement to pay after a thorough informed consent process where you have outlined other options (and documented doing so!)
But I can’t stress enough that it’s not ok in most states!
Even in the states that allow collecting from Medicaid clients, it’s only under specific circumstances. For example, if the service you are providing isn’t covered by the state’s Medicaid program.
Do your homework before presuming collecting from a Medicaid client is ok. Yes, I get it: documents written in Medicaid jargon aren’t easy to interpret.
Be very careful if you proceed with this one: there’s a reason people have Medicaid, right?
Myth #12 Insurance can’t audit my records if I’m out of network.
Fact: Any claim that is submitted to insurance can be audited. Network status is irrelevant.
If they pay for treatment, they have the right to review records for “medical necessity” – either before or after paying the claim.
Read box 12 of the 1500 claim form. Claim forms submitted by clients with a superbill attached have the same exact lingo on them.
“I authorize the release of any medical or other information necessary to process this claim.”
If the payer wants to scrutinize records, then they can. Even self-pay is not 100% protection against audits. You can choose not to contract with insurance payers, but you’re not allowed to forbid clients from attempting to get reimbursement from THEIR health insurance.
This means if the client tries to be reimbursed, and the payer wants to see your records…hand them over! Being out of network isn’t a justification. The only reason you have to withhold the records is if the client withdraws their consent to the release of the information – in writing.
Do you have any other suspicions that something you’ve always believed might turn out not to be true?
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 1. If you didn’t get a chance to read it, check it out here. Those Darn Deductibles – Part 1
The Questions You Need to be Answered, but were Afraid to Ask
Ok, onward! Let’s dive into more detail here in part 2
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.
Usually, 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).
Perhaps 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 is another 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 think 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.
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.
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!
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.
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:
Therapy – and your expertise – is valuable.
If the client is going to be fully engaged in therapy, they must make a financial and emotional investment into the process.
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:
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.
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!
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!
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 deductibleand 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!
SAY WHAT? REALLY?
Yep. The precedents here have been set by thefederal 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).
AS LONG AS WHAT YOU ACTUALLY INTEND TO COLLECT FROM THE CLIENT IS THE PRICE YOU INDICATE ON THE CLAIM FORM. To do otherwise is a False Claim; i.e. insurance fraud.
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.
If 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.
If you are going to waive some part of a client’s financial responsibility, follow the old axiom we heard repeatedly in graduate school:
If it isn’t documented, 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 want your practice to be financially healthy…right?
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.
With most health plans, benefits renew on January 1. Yeah, the dial goes back to ZERO. It’s the most awful time of the year.
Let’s begin by looking at what a deductible is. It is the amount a client must pay IN FULL out of their pocket, each plan year before an insurance policy will make ANY payment. That means your clients are responsible to pay the contracted fee in full for sessions if you are in-network with their plan.
If you are out of network, the client is responsible for paying the full amount you bill to the insurance plan. OUCH.
Once the clocks turned over on January 1 at 12:01 am., there’s now a different mindset you’ll have to adopt in the coming weeks, to protect YOUR income! You work hard with clients and it’s so discouraging if you don’t get paid.
What will you do this New Year to avoid a drastic reduction in income??
Talking about money with clients is something many therapists find difficult.
Often it is because we have money challenges of our own that have not been addressed. Some of it may simply be a lack of business knowledge. Graduate programs don’t teach the business aspects of private practice. Internships may or may not offer a glimpse of financial management, but internships often don’t occur in private practice settings. Many newly-licensed therapists start out working for large group practices, which may have in-person employees whose job it is to collect the money.
The new online venture-capital-backed enterprises, such as Headway or Alma, also give therapists no experience in directly requesting fees for therapy – the platform collects for you.
By the time therapists are ready to open a private practice, we’re woefully unprepared for the reality of having to ask the client to pay for their session.
It can be hard to play two roles, that of both therapist and businessperson. However, IT IS POSSIBLE if you are prepared and know how to manage finances with your clients.
Here are 8 SPECIFIC recommendations to help you with getting paid:
1.Take care of the “business” part of the session at the beginning of the hour. It’s much easier to collect money before dealing with serious emotional issues. You haven’t yet sat with the client’s pain for an hour. You can say to the client, let’s take care of your payment now so we can focus on you for the rest of your time! They LOVE this because they see you care about them and not just their money. Furthermore, at the end of a session, your task is to make sure you end on a hopeful note, give homework, wrap everything up, make notes, and schedule the next appointment. Collecting money adds yet another task. If the session runs late, you also have the complication that your next client might be waiting for you, and it’s tempting to put off collecting money until next time. And the next…and so on.
2. Collect something each visit, even if it’s an estimated amount. Develop consent forms that clearly explain what your policy is and your reasons for it. And if you’ve put a policy in writing…then stick to it! Consistency is therapeutic. If you waver in your management of the financial side of your business – you won’t last long! There’s a saying “You can’t take HOPE to the bank”! In other words, you MUST be in charge of your money and not your money be in charge of you.
3. Don’t ask “Do you want to pay today?” Instead, ask “HOW would you like to pay today?” Words are so very important! This one three-letter word demonstrates your expectations to your client and gives them an understanding of what they need to do. Put it in therapeutic terms for yourself: You are setting boundaries and letting the client know that payment is not optional. You must establish this from session #1! This keeps you from resenting your client and frees you to do what you do best – therapy. If you have currently-established clients who are falling behind in payments, the first of a New Year is the perfect time to revisit and set those boundaries. DO IT NOW!
4. Keep a credit card on file and suggest an autopay arrangement.
These days, with so many clinicians working online, it is essential. But even if you are seeing clients in the office it is best practice to have a card on file.
Whenever we subscribe to a service for ourselves, it is common to place a credit/debit card on file with that service. WHY should you be any different? You are providing a valuable service. I’ve discovered even with merchant fees being 2-3%, therapists still come out ahead if they use a credit/debit card autopay arrangement.
Consider this: If you didn’t have the service/option of charging credit/debit cards…
Some clients can or will not use cash or checks.
If you see clients online – how would you get paid?
Many patients want to pay with Health Savings Accounts or Flex Spending cards – which are typically only debit cards, not an account on which they can write you a paper check.
Prior to instituting payment on file arrangements, a “good” client collection rate using traditional mailed bills was roughly 80%. If you can raise that higher than 83% (and you can – most autopay practices net over 95%!) then you’ve negated the merchant fees and come out ahead. Plus, merchant fees are tax-deductible business expenses.
When a client leaves your office without making a payment, you’ve reduced your chance of getting paid by 50%.
Might as well flip a coin…
Because you just gave up control of YOUR income!
5. Money can often be an emotional subject… But don’t avoid your client’s feelings or challenges around money. Work on it as you would any other therapeutic issue. Ignoring or not talking about payment tells your client that “it’s not all that important. My therapist will understand if I don’t pay them.” Is that really the message you would like to send?
6. That said, don’t ignore your own emotions and issues around money. Do what you need to do to address them. Reach out to a business coach, a colleague you respect, or a therapist who specializes in this area. Running a business isn’t for the weak. Give yourself some credit for what you have already accomplished, but understand that NO ONE DOES IT ALONE!
7. Discuss concerns you have with your clients. For instance, you can say: “Asking you to pay something every visit is to ensure the bill never gets so high that it becomes a source of anxiety for you.” “I don’t want there to be any surprises for you when it comes to the bill.” “Please, always talk to me if you are having problems paying your therapy bill.” The important points here are
model open, honest communication
handle your own money challenges
part of being a professional is managing your business finances
never let the therapy bill become the big elephant in the room – the issue no one talks about. If for no other reason than…how therapeutic is that?
You need to get paid!
8. Practice makes perfect. It may seem obvious, but it’s true. The more you follow the above seven steps, the easier you will find the task of handling finances with patients in a businesslike, non-emotional manner. And the flip side is…the more you avoid or procrastinate at it, the HARDER it gets. There’s only one time to start, and that’s NOW.
At all times, your behavior around financial issues should model the healthy,
adaptive behaviors that you are trying to help your client learn.
DO NOT ALLOW A CLIENT’S BALANCE TO BECOME SO HIGH THAT:
It becomes a source of anxiety for your client.
It becomes a source of anxiety and/or resentment for you.
It becomes uncollectible and you are giving away free services.
If at all possible, you should never allow a client to carry a balance. At worst, stay no more than one visit behind. In Part 2, I will discuss how insurance factors into this.
Managing deductibles is a constant revenue cycle of
posting, collecting, reconciling, invoicing
and repeat…and repeat!! Like self-employment in general, it’s not for the faint of heart.
Given that high deductibles are so common, I’m always surprised that more therapists don’t ask me this important question:
If I’m in-network, am I allowed to collect my full contracted rate ahead of the claims being submitted/adjudicated?
That’s the first question I’ll answer when you join me here next week for Those Darn Deductibles – Part 2: The Questions You Need to have Answered, but Were Afraid to Ask.
WAIT!!! Don’t go yet!
Why didn’t you discuss Verification of Benefits? Isn’t that a strategy you recommend?
Absolutely! Verify eligibility & benefits, file claims promptly (and electronically), and use employee-assistance benefits at the start of the year (if available). Make sure insurance claim results are credited and client payments are posted in a timely manner and reconciled so that you know what to collect BEFORE the client shows up.
But even with all of that, there is always uncertainty when dealing with insurance. Part 2 of “Those Darn Deductibles” dives further into those headaches.
Verification of benefits can be a painful topic. I can talk about it for hours, it’s a multi-headed beast. But it doesn’t have to be painful! So…
If you’re billing insurance out of network, you will eventually receive faxes or emails like this:
Who are these people, and why are they contacting me?
There’s a whole industry of third-party re-pricers and “passive PPO’s.” Multiplan is just one of many out there.
A “re-pricer” is just what it sounds like: an entity that looks at a claim and decides what is the “allowable” amount.
Sometimes, it’s not who you think it is who decides how much you’ll be paid…..
A “passive PPO” is an alternative provider network that serves as a backup to the original payer’s panel, another method to force a discount on out of network claims.
Here’s the shell game: You are out of network but submit a claim to an insurance payer so that the patient can get out of network reimbursement. (It doesn’t matter whether you’ve accepted assignment or not). The payer looks at the claim, your NPI/tax ID and sees that you are out of network.
If the payer, let’s say it’s Cigna, has an arrangement with a third-party party re-pricer such as MultiPlan, then the claim is sent to MultiPlan by Cigna before any action is taken.
MultiPlan’s job is to contact the doctor (YOU) and offer a discount. Keep in mind that they don’t work for free, either.
The fax makes it sound as if you won’t get paid promptly unless you agree to the discount.
“Your acceptance may expedite payment…”
They mislead a lot of people into giving discounts with that language. Don’t be fooled. All states have “prompt payment” laws that specify how long an insurer has to adjudicate a “clean” claim. If the claim was sent to Multiplan, then by definition, it was accepted for adjudication and is “clean.” If the insurer doesn’t respond within the time frame, they must pay you interest.
By telling you acceptance of these terms means you will decrease your patient’s cost share, this is true…but not the whole picture. Acceptance does reduce the amount the patient has to pay, but it does NOT put you into the network or shift the benefit level back to “in-network.” The patient will still only receive the out of network benefit level.
When you receive one of these offers:
It is ok to ignore it and within a couple of days the passive PPO is required to return the claim back to the payer, who will process it as they originally would have done without the re-pricer’s involvement.
If I have time, I enjoy calling them and (politely) telling them to get lost. I also ask them to remove the provider’s TIN / NPI from this member’s claims. Otherwise, they will continue to send offers for each date of service.
If the patient paid in full at the time of service and you are filing for them to be reimbursed (or if the re-pricer is responding to a superbill submitted by the patient), do not negotiate; you will be cheating your patient unintentionally.
If your patient is having financial difficulties affording out-of-network treatment, this is a legal way to offer a discount on the full billed charge after the claim is submitted.
You *will* receive these offers even if the patient’s deductible has not been met. If you have agreed to the discount, you cannot charge the patient what you originally billed; you must charge them only what you agreed to.
If it’s a situation where you thought you were in network for a particular patient, and then you turned out not to be, accepting a discount might smooth over difficulties from a clinical perspective.
Be careful not to mark the box that says, “I accept a global fee agreement to eliminate the need for case by case faxes.” This puts you in network with the passive PPO…and forces discounts with any payer who chooses to hire them. You will be giving discounts where you don’t intend to – but the patients won’t get better benefits unless the passive PPO is their primary network (it can happen, with smaller payers).
You will not receive these offers if the patient has no out of network benefits.
Whatever your reasons for considering a deal, you can certainly attempt to get a better rate than what they first offer. I’ve found reps willing to go as high as 50% of the amount they are trying to write off.
Re-pricers only have the power to adjust the final allowed amount; they do not get to determine what/how much is covered, paid, denied, or applied to the deductible. Nor can they quote benefits. For any of that, you must continue to work with the payer.
A telehealth claim during the COVID-19 Public Health Emergency (PHE) is submitted to the primary plan, a commercial plan that requires Place of Service (POS) code 02 or 10 and modifier -95. The claim applies to the deductible. The patient has Medicare as his secondary plan, and the telehealth claim is duly forwarded to Medicare without changing the telehealth place of service coding.
Providers must accept lower reimbursement for services, because The Powers That Be can’t (won’t?) get together and agree on how telehealth should be submitted? It’s the middle of 2022. Haven’t we lived with COVID and telehealth now for long enough that they should have figured this out?
It would be fraud to change coding on the claim after the primary plan considers it, right?
The opposite also happens:
A provider submits a telehealth claim to Medicare using the PHE coding. Medicare pays correctly and forwards the claim to the secondary payer, which is not a Medigap plan. In mental health billing, some commercial insurance plans use specialty behavioral health vendors known as “carve-outs,” where the entity who pays mental health claims is independent of the insurer who handles the medical benefits. This plan was one such. Because non-Medigap plans do not have to follow Medicare guidelines, the secondary payer in this case didn’t adjudicate the claim but denied it back to the provider stating they were not the correct payer. The provider is then required to file a manual claim to the secondary payer’s behavioral carve-out to obtain reimbursement. This was done without changing the telehealth coding, and the behavioral plan denied the claim: INCORRECT CODING. An appeal was submitted explaining that the provider was following Medicare guidelines, and included a copy of Medicare’s directive for coding PHE telehealth claims. The appeal upheld the denial: “the telehealth coding is incorrect.”
The provider was acting ethically by not adjusting coding after the fact. Now she must lose out on the reimbursement – because it certainly would not be fair to charge the patient.
Is there a solution here? Can coding be changed ethically? Is it fraud? Abuse?
He first clarified the difference between “fraud” and “abuse,” which I think is an important distinction. In his words,
“Medical billing fraud and abuse arises mainly due to medical coding and
billing errors which lead to improper reimbursements. Fraud is a deliberate
deception that results in an unauthorized payment, while abuse is failing to
adhere to accepted business practices.”
It seems that we’re not contemplating fraud here – if you provided a telehealth service, that’s what you provided and there is no deception.
Mr. Schiffman agreed.
“It would not be considered fraudulent if the medical record
documentation supports the … claim being submitted, and the
code was just being updated with a corrected code.”
But he cautioned that providers need to:
1) refrain from altering the documentation after the fact, just to support a corrected claim; and
2) make sure that the codes on the corrected claim do in fact reflect the medical record.
Abuse seems to be the issue here: failing to adhere to accepted business practices. in this instance, accepted practice is to keep codes consistent between the primary and the secondary payer.
I also asked Mr. Schiffman about the two scenarios above.
“I discussed these scenarios with our Coding and Auditing Manager. On the
first scenario, she pointed out because it applies to the deductible, she is
uncertain if Medicare will allow the coding to be changed and resubmitted.
We looked for guidance and came up blank on that. She recommends
contacting the MAC, explaining the scenario, and seeing if they allow a
corrected claim after it was already submitted to the commercial payer.”
“For scenario 2, while we do not see an issue from a compliance perspective
correcting and resubmitting the claim to the secondary payer, we would
recommend contacting the payers directly and seeing if they allow it or
what their process is.”
Ok, so if the best minds in Compliance “came up blank,” then how is a solo provider, with no coding background and no staff, supposed to get it right?
Good point! My advice: proceed with caution.
While contacting the MAC or a private payer seems to be a logical step, most likely the customer service rep will tell you that they are not allowed to tell providers how to code. They will say “code according to your documentation and best practices.” Which puts you right back where you started. And even if you did, by some chance, get a CSR to answer you…what guarantee do you have that this rep gave you the correct answer? In an audit, would that stand up?
My recommendation is to play it safe: unless the MAC or private payer is willing to answer your question and give you permission in writing … then, don’t.
Yes, it’s unfair, and it sucks not to be fully paid – but the consequences of altering coding between a primary and secondary payer could be far worse.
Tired of being short-changed?
I don’t blame you – it’s unjust.
Are the professional organizations aware of the elephant in the room? What are they doing to rehome him back into the wild, and represent you?
A patient comes to you, says I have Medicare primary and then United Healthcare. You bill in that order, but are puzzled when Medicare denies the claim with the following reason code:
CO-109: CLAIM/SERVICE NOT COVERED BY THIS PAYER/CONTRACTOR.
Now what do I do?
You are a counselor or marriage and family therapist who cannot accept Medicare. A patient starts treatment and gives you an Aetna card. Aetna pays you – but a year later they claw back the money, stating you weren’t entitled to it because your license isn’t eligible for Medicare. But when you called to verify benefits, you were told you were in network and the patient had benefits to see you.
The patient had Aetna! What does Medicare have to do with anything?
You have several patients with BCBS and are in network. However, your claims come back paid at a different (lower) rate than usual, plus a small deduction marked “sequester.” Over time, it’s added up to hundreds of dollars. You try to figure it out and get nowhere.
No one seems able to explain it and they pass me around to different departments.
You are a Medicare provider. You’ve been seeing a patient with Medicare and a supplement for years. Suddenly, Medicare denies your claims, stating they aren’t the correct payer. You don’t understand.
How can someone have Medicare, stay retired, but then suddenly have something else for insurance?
WHY do they make this so confusing?
The one thing that all these scenarios probably have in common is that the patient may have what’s known as a “Medicare Advantage” policy.
The mental health community is often confused about what Medicare Advantage is and isn’t – so Your Billing Buddy is going to set you straight, because it often seems like no one else will.
In brief, without any technicalities, judgments, or public policy justifications/disputes for the existence of the Medicare Part C program (AKA Medicare Advantage) … these are alternative commercial plans that Medicare beneficiaries are allowed to choose. Once enrolled in Medicare Advantage, any claims to Original Medicare will deny with the above reason code that Medicare is not the correct payer.
(An exception – because there must always be one, right? – If your patient is hospice enrolled, you will go back to billing Original Medicare, with a hospice modifier).
That was about 26 million people – so if you haven’t yet seen one of these common scenarios in your practice, you will. It’s only a matter of time, especially given the aging demographics of the population.
So how do I protect myself from denials, clawbacks, and fee erosion?
There are only two things you need to do to avoid the tricky trap of Medicare Advantage:
Get their Insurance Cards
After 24 years as a biller for mental health services, I’m still shocked by how many providers (and their EMR systems) do not feel it necessary to capture this information. Insurance cards have all sorts of logos on them that provide valuable information.
All Medicare Advantage cards are easily identifiable. Terms such as Medicare Advantage, A Medicare Private FFS Plan (fee for service), or [Payer name] Medicare are usually prominently displayed. Also, look out for cards marked Dual and/or SNP – these are Medicare Advantage plans for patients who are also eligible for Medicaid and combine both benefits into one policy.
Some examples (there are many)
Read the fine print of the section that shows you the funding source of the plan. (Although a card like the above would tell you all you need to know).
So ok, they have Medicare Advantage. Now what? Can I take this plan?
But: You do NOT have to participate in the network of the Medicare Advantage payer offering the benefits. If you aren’t, you will be paid 100% of the Medicare fee schedule. If you signed the CMS-460, you cannot balance bill. Non-participating providers may bill up to 115% of the Medicare allowable rate, just as they can with Original Medicare.
In fact, it may be preferable NOT to contract with Medicare Advantage plans. The Original Medicare allowed amount is typically anywhere from 10-40% MORE than you would be paid if you were a participating provider in a Medicare Advantage network.
The sequester applies to reimbursement from both Original Medicare and Medicare Advantage, so while it is not part of the reason why Medicare Advantage plans pay less, it is a clue that your patient with a commercial plan in fact has Medicare Advantage.
Caution: there are Medicare Advantage plans that do not offer out of network benefits – so you have to verify if there is out of network coverage. Medicare Advantage patients who have no out of network benefits have the same choice as any other patients with policies not featuring out of network coverage: self-pay or choose another provider.
Original Medicare providers are under no obligation to participate in Medicare Advantage plans.
Nor do they have to opt out in order to accept a Medicare Advantage patient who wishes to self-pay. Also, no ABN is required for Medicare Advantage patients.
I find that the biggest trap of all with Medicare Advantage, is the fact that patients don’t always understand it. When they call for service, they give incorrect information, and busy practitioners without a lot of support tend to take patients at their word. Remember, your patient isn’t trying to deceive you – but this stuff is hard to understand, or you wouldn’t be reading this blog. So, understanding your patient’s plan type could save you hundreds if not thousands of dollars later in denied or clawed back claims.