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Online information can be years out of date, of questionable reliability, and may not be generalizable to your problem, payer, specialty, or location.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?
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.