Billing Insurance For Tardy Clients: Strategies For Efficient Practice Management

Billing insurance for late clients can be a tricky process, and it depends on a few factors, such as the type of insurance, the company's policies, and the client's payment history. Late fees and policy cancellations are common when payments are missed or delayed. To avoid this, it's important to understand the billing options, payment methods, and potential grace periods offered by the insurance company. For therapists billing for therapy sessions, proper credentialing and understanding the correct billing codes are crucial to ensure prompt and accurate reimbursement.

Billing cash vs billing insurance

Billing cash versus billing insurance has its pros and cons. Billing cash can save patients money in the long run, especially if they have high deductibles. When patients pay in cash, clinics can offer services at a discount or cheaper than the negotiated health insurance amount. This saves the clinic time and money, as they don't have to go through insurance companies. However, the risk for patients is that they will have to pay their full deductible after already paying for cash services. The risk for clinics is that patients may never pay, leaving the clinic to cover the service.

On the other hand, billing insurance is a more stable option. Insurance companies will pay an allowed amount and leave issues with patient non-payment to their collection agency. However, billing insurance can be time-consuming and complicated, as clinics may have to spend more time and money negotiating claims. Additionally, patients with high-deductible insurance plans may benefit more from paying in cash, as they have to pay thousands of dollars in medical costs before their insurance kicks in.

It is important to note that opting out of insurance and paying in cash might not always be the best option. For instance, patients may not receive the same consumer protections offered by their insurance plan, and they won't be chipping away at their annual deductible. Thus, paying cash is more suitable for patients with high-deductible plans but may not be beneficial for families with a low deductible or out-of-pocket maximum.

Overall, both billing cash and billing insurance have their advantages and disadvantages. Patients and clinics must carefully consider their specific circumstances and needs before deciding which option to choose.

Getting credentialled with insurance companies

Medical credentialing is the process of getting networked with insurance companies, often described as "getting on insurance panels". It is a popular term among healthcare providers, especially among counsellors, chiropractors, and massage therapists.

• Make a list of the companies with which you want to be credentialled. It's best to choose the largest insurers in your area. You may also want to ask other therapists about their experience working with specific insurers.
• Apply to become part of the insurer's provider panel. Most insurers offer an application on their website.
• Complete the Council for Affordable Quality Healthcare (CAQH) application. Most major insurers require the CAQH application as part of their credentialing process. You will need to apply to the insurance company for credentialing, receive a CAQH number, and only then will you be able to complete the CAQH application.
• Follow up with each insurer to which you apply. It can take several months to get approved, and you may need to provide supplemental information.

The process of "credentialing" or "provider enrollment" with an insurance network consists of two phases: credentialing and contracting. The credentialing phase is when the insurance company verifies your credentials and that you meet their requirements for participating in their network. The contracting phase is where the company issues you a participating provider agreement that defines the terms of participation for receiving in-network reimbursement for your claims.

Credentialing opens up a whole source of clients to a therapist. While some people can afford to pay for a therapist out-of-pocket, most need to use insurance to afford the costs. Credentialing also allows you a certain flexibility. If you switch jobs, your credentialing follows you.

Common challenges of the credentialing process

• Time-consuming. Depending on the company, it can take months to get approved.
• Detailed. Make sure you fill in every blank of your application or it will be returned, elongating the process.
• Competitive. You are most likely to be approved if you can offer qualities that other therapists don’t possess, such as speaking another language or the ability to work uncommon hours.

Filling insurance paperwork

Filling out insurance paperwork can be a complex process, and it's important to ensure that it's done accurately and promptly to avoid delays or issues with reimbursement. Here are some detailed steps to help you navigate the process:

Understanding the Credentialing Process:

Before you can start billing insurance companies directly, it's essential to become credentialed with the insurers you plan to work with. This typically involves applying to join their provider panel. Most insurers will have an application process outlined on their website. As part of this process, you will likely need to complete the Council for Affordable Quality Healthcare (CAQH) application, which is a standard requirement for many major insurers. The CAQH application will require you to provide detailed information about your qualifications, experience, and the services you offer.

Selecting the Appropriate CPT Codes:

When billing for mental health services, it's crucial to use the correct Current Procedure Terminology (CPT) codes. These codes depend on the specific procedure performed and the duration of the session. Common CPT codes for therapy include codes for individual psychotherapy (e.g., 90832 for 30-minute sessions, 90839 for 60-minute crisis sessions), family psychotherapy (e.g., 90847), group psychotherapy (90853), and neuropsychological testing (96132). It's important to refer to the most recent CPT manual to ensure you are using the correct and updated billing codes.

Documenting Each Treatment Session:

Maintain detailed records and documentation for each client visit. This includes recording the start and end times of the session, the services provided, and any relevant notes. Proper documentation is essential to support your billing claims and can be requested by insurers during audits or reimbursement reviews. Inaccurate or insufficient documentation may result in delayed payments or even removal from the insurer's provider panel.

Following Insurer Guidelines:

When you are accepted as a provider, insurers will typically provide you with a detailed guide to their billing process, including specific requirements and covered services. It's important to carefully review and adhere to these guidelines to ensure prompt and accurate reimbursement. Each insurer may have unique requirements, so be sure to familiarize yourself with their processes.

Submitting Claims Within Deadlines:

The timeframe for submitting claims varies among insurers, and it's crucial to adhere to their specified deadlines. For example, Medicare and Medicaid typically allow 365 calendar days from the date of service, while private insurers often set shorter deadlines, such as 90 days. To simplify the process, consider using the shortest filing period across all the insurers you work with as your standard deadline for submitting all claims.

Understanding Reimbursement Policies:

Therapists are generally entitled to reimbursement within 30 days of submitting a claim. However, coding errors or other issues can cause delays. Stay organized and follow up with insurers if you haven't received payment within the expected timeframe. Additionally, discuss insurance policies and reimbursement rates with your clients upfront to manage their expectations and ensure a smooth billing process.

Deadlines and payment schedules

• Understanding Deadlines: The deadline to submit a claim for payment varies among insurers. Medicare and Medicaid typically allow up to 365 calendar days from the date of service, while private insurers often set shorter deadlines, such as 90 days. It's essential to review the provider panel documents for clear guidance on deadlines.
• Juggling Multiple Insurers: If you work with multiple insurers, it can be challenging to manage different deadlines. To simplify this, identify the shortest filing period among all the insurers and aim to file all claims within that period. This approach ensures you don't miss any deadlines.
• Reimbursement Timeline: Therapists generally have the right to be reimbursed within 30 days. However, coding errors or other issues can cause delays. Keep track of each bill sent out, and if reimbursement is not received within the expected timeframe, follow up with the insurer to inquire about the status.
• Grace Periods: Some insurers offer grace periods for late payments, which can range from 30 to 60 days. During this time, they may not charge late fees or terminate coverage. However, if the grace period elapses without payment, late fees may apply, and continued non-payment can lead to policy cancellation.
• State-Specific Variations: It's important to note that grace periods and late payment policies can vary by state. For example, New York does not permit grace periods on any type of insurance. Always review the regulations in your state to understand the specific rules that apply.
• Prompt Notices: Insurers are required to send prompt notices regarding payment delinquency. Within 10 business days of a missed payment, they should notify the policyholder, providing transparency around the situation.
• Health Maintenance Organizations (HMOs): Under Maryland law, HMOs must give providers a minimum of six months from the date of service to submit a claim for reimbursement. If a provider fails to submit a claim within this timeframe, they cannot bill the HMO enrollee for covered services.
• Commercial Indemnity Insurers: In Maryland, commercial indemnity insurers are also required to provide a minimum of six months for providers to submit reimbursement claims. However, providers can generally pursue payment from patients if the insurer denies the claim due to the expiration of the billing time limit.
• Medicare and Medicaid: These programs typically offer a more extended timeframe for submitting claims, such as 365 calendar days from the date of service. Additionally, they have specific rules regarding grace periods and claim payments.
• Self-Insured Employer-Sponsored Health Plans: These plans set their own time limits for submitting invoices, often around 90 days. There are no legal protections for patients regarding late payments, so the debt remains the patient's responsibility even if the provider misses the plan's deadline.

Getting insurance payouts

Firstly, it is important to discuss insurance policies with your clients. Verify insurance coverage and reimbursement rates with new clients and ask them to notify you if they switch insurance providers. Many insurers only offer coverage once a client hits their deductible, so discussing this with your client at the first therapy session is important so that they know they may have to cover some sessions themselves. If your client changes jobs, make sure they are aware of COBRA benefits, which will continue to cover therapy as they seek new employment.

Secondly, establish and discuss policies for when insurance denies a claim. Decide whether the client is responsible for payment in this case. It is also important to know the specific policies an insurer requires you to follow. For example, some insurers require pre-authorisation for some services or will only cover treatment if the client is diagnosed with a specific condition. Knowing whom to contact with billing questions is also important. Keep a log of previous calls and contacts so you know which strategies are most effective.

Frequently asked questions