Untangling The Billing Process: Understanding Co-Treatment Insurance Claims

The billing process for co-treatment can vary depending on the therapist and the insurance company. Typically, the therapist or counsellor will bill the insurance company directly, and the patient will be responsible for paying the co-insurance or copay. In some cases, the patient may need to pay out-of-pocket first and then be reimbursed by the insurance company. The amount of the copay or co-insurance will depend on the specific insurance plan and the type of service received. Mental health services may be treated separately from other healthcare services and may not be subject to a deductible. It is important for the therapist to confirm the patient's coverage before or during the first visit to avoid any surprises regarding billing and payment.

The therapist or counsellor will bill the insurance company and the patient pays co-insurance or a copay.

Typically, a therapist or counsellor will bill the insurance company and the patient pays co-insurance or a copay. This means that the therapist or counsellor will handle the billing process, and the patient will only need to pay a portion of the total cost, which can be either a copayment (copay) or co-insurance (coinsurance).

Copayments are flat-rate fees, usually ranging from USD $10 to $30 per session, that are paid directly to the therapist or counsellor at the time of the session. The amount of the copayment is determined by the patient's insurance plan and remains the same regardless of the cost of the session.

On the other hand, coinsurance is calculated as a percentage of the total cost of the session. For example, if a patient's insurance plan has a 30% coinsurance rate, they will pay $30 for a $100 session ($100 x 0.3 = $30). The insurance company will then cover the remaining 70% ($70).

It is important to note that therapists and counsellors should confirm the patient's insurance coverage before or during their first visit. In some cases, patients may need to pay out-of-pocket first and then be reimbursed by their insurance company. Additionally, mental health care coverage may vary and may be subject to different rules and regulations than other types of healthcare.

To ensure accurate billing and reimbursement, therapists and counsellors must use the correct Current Procedural Terminology (CPT) codes when billing insurance companies. These codes are standardised, five-digit numbers that correspond to specific types of medical services, such as psychotherapy, family psychotherapy, and group psychotherapy. Proper coding is essential to receive prompt payment and avoid issues such as audits or removal from an insurance provider's network.

The patient may need to pay out-of-pocket first and then be reimbursed by the insurance company

In some cases, patients may need to pay out-of-pocket first and then be reimbursed by their insurance company. This typically occurs when a therapist or counsellor is not credentialed with an insurer and bills the patient directly. The patient then needs to seek reimbursement from the insurer, which is not always guaranteed. This can be a financial burden for the patient, who is responsible for the bill, and may cause them to attend therapy less frequently.

It is worth noting that therapists and counsellors who are not credentialed with insurers are those who are considered out-of-network. In contrast, in-network therapists and counsellors have agreed to a negotiated rate with the insurance company for therapy sessions. In this case, the patient will usually pay a copayment, or copay, a flat-rate fee per session, which is typically $30 or less.

If a patient sees an out-of-network therapist or counsellor, they may be billed the full cost of the session upfront. They will then need to submit this to their insurance company to be reimbursed. This process can be time-consuming and complicated, and reimbursement is not always guaranteed. The insurance company may only reimburse a portion of the session cost, depending on the patient's coverage and plan details.

To avoid this, patients can ask their therapist or counsellor to provide a Super Bill or invoice detailing the services received and the amount paid. The patient can then submit this to their insurance company to request reimbursement. However, even with a Super Bill, reimbursement is not guaranteed, and the patient may still need to pay out-of-pocket first.

It is important for patients to understand their insurance coverage and plan details before starting therapy to know what costs they may be responsible for. They should also confirm with their therapist or counsellor about their coverage and billing process to avoid unexpected expenses.

Mental health coverage may only take effect after the patient meets their annual deductible

Mental health coverage may not take effect until a patient meets their annual deductible. This means that the patient must pay for their mental health treatment out-of-pocket until they have paid off their deductible. The deductible is the amount that the patient must pay before their insurance company will start to pay for their treatment. The amount of the deductible varies depending on the insurance plan.

The deductible is part of the patient's out-of-pocket costs, which are the costs that the patient must pay themselves. Out-of-pocket costs include deductibles, copayments/copays, and coinsurance. Copayments/copays are a set fee that the patient pays each time they receive a specific health care service, whereas coinsurance is a percentage of the total cost that the patient pays.

The Mental Health Parity and Addiction Equity Act (MHPAEA) requires insurance companies to treat mental and behavioural health and substance use disorder coverage the same as (or better than) medical/surgical coverage. This means that insurers must apply the same financial requirements to mental health coverage as they do to medical coverage. For example, insurers cannot charge a higher copay for office visits to a mental health professional than they do for most medical/surgical office visits.

In addition to the deductible, health plans will also have an out-of-pocket maximum, which is the maximum amount that the patient will have to pay for their medical expenses in a year. Once the patient reaches this limit, the insurance company will pay for the rest of their costs for the rest of the year.

The therapist must be credentialed with the insurance company to bill them directly

Credentialing: The Key to Direct Billing

Therapists who want to bill insurance companies directly must be credentialed with the insurer. Credentialing is a process of verification that confirms a therapist's qualifications and experience as a mental health professional. It is a prerequisite for joining an insurer's provider panel and being able to bill them directly. Without credentialing, therapists cannot bill insurance directly, and clients must seek reimbursement from the insurer, which is often a challenging and uncertain process.

The Credentialing Process

The therapist must first decide which insurance companies to apply to for credentialing. They should consider factors such as the insurer's market share in their region, the reimbursement rates, the ease of working with the payer, and the specific requirements and restrictions of the insurance company.

Once they have identified the companies, therapists should make a list of the necessary documents, which typically include:

• Professional liability coverage details
• License to practice
• Practice tax ID number
• Completed application form

After gathering the required documents, therapists submit them to the individual insurance company networks. The process may vary slightly between companies, so therapists should check the specific requirements of each insurer. The credentialing process can take several months, and therapists may need to follow up to ensure their application is received and approved.

Benefits of Credentialing

Credentialing is beneficial for both therapists and clients. It helps build trust between clients and therapists and demonstrates that the therapist meets the standards set by insurance companies. Credentialing also increases the likelihood of insurance companies working with the therapist. Additionally, being credentialed with insurance companies can lead to referrals from the insurers, helping to attract more clients.

Drawbacks of Credentialing

One of the main drawbacks of credentialing is the time it takes to complete the process. Therapists may have to wait two to four months for approval, which can be challenging when establishing a new practice. Another disadvantage is the administrative burden of billing insurance companies directly. Therapists must use the correct medical codes and billing procedures, which can be time-consuming and may require dedicated staff or outsourcing to a billing service.

In conclusion, while credentialing with insurance companies allows therapists to bill them directly, it is important to consider the benefits and drawbacks of this process. Therapists should carefully weigh their options and decide if credentialing aligns with their practice goals and revenue targets.

The therapist must select the right Current Procedural Terminology (CPT) code for the treatment

To ensure that the therapist is reimbursed for their services, they must select the right Current Procedural Terminology (CPT) code for the treatment. CPT is a standardised set of codes, descriptions, and guidelines that describe medical, surgical, and diagnostic services and procedures. CPT codes are used by healthcare providers to communicate uniform information about medical services and procedures to patients, payers, accreditation organisations, and others for administrative, financial, and analytical purposes.

CPT codes are divided into three categories. Category I CPT codes are the most common and cover procedures, services, and contemporary medical practices that are widely performed. These codes are identified by a five-digit numeric code and range from 00100 to 99499. Category I codes are widely accepted by third-party payers and are considered the "usual" CPT codes.

Category II CPT codes are supplemental tracking codes used for performance measurement and data collection on patient health outcomes and quality of care. These codes consist of four numbers followed by the letter "F" and are not linked to reimbursements. Category II codes are optional and are typically assigned in addition to Category I codes.

Category III CPT codes are temporary tracking codes for new and emerging technologies, services, and procedures. These codes consist of four numbers followed by the letter "T" and are used to collect data and assess new services and procedures that do not meet the criteria for a Category I code. Payors require a valid Category I and/or Category III code for payment consideration.

Therapists must select the appropriate CPT code based on the type of service or procedure provided, as well as the length of time it took. For example, the CPT code for a 30-minute psychotherapy session is 90832, while the code for a 60-minute crisis psychotherapy session is 90839.

It is important to note that CPT codes are updated annually by the American Medical Association (AMA) to accommodate changes in the healthcare industry. Therefore, therapists should refer to the most recent CPT manual to ensure they are using the correct codes for their services.

Frequently asked questions