Billing Insurance In Private Practice: A Guide To Get Started

Billing insurance in private practice can be a complicated and intimidating process, but it's a critical part of running a successful therapy business. While graduate programs often don't teach therapists about insurance billing, it's essential to understand the steps involved to get reimbursed for therapy sessions. This process typically includes credentialing with insurance companies, understanding insurance requirements and codes, submitting claims, and tracking payments. By following the proper procedures and staying organized, therapists can navigate the world of insurance billing effectively and ensure they receive timely reimbursement for their services.

Understanding the basics of insurance billing

Billing insurance for therapy sessions can be a complicated and frustrating process. However, by following some key steps, you can successfully navigate the world of private practice insurance billing. Here are the basics you need to know:

Credentialing

The first step is to get credentialed with insurance companies. This process, known as medical credentialing, allows therapists to join an insurer's provider panel. It usually involves applying through the insurer's website and completing the Council for Affordable Quality Healthcare (CAQH) application. Getting credentialed is essential if you want to bill insurance directly and avoid the reimbursement process, which can be uncertain and time-consuming for clients.

Choosing Insurance Panels

With thousands of insurance companies out there, deciding which panels to contract with is crucial. Consider factors such as contracted rates, geographic demand, panel needs, and the ease of insurance billing when making your selection. Do your research and talk to colleagues to make an informed decision.

Understanding Contracts

Once you are credentialed and have a contract with an insurance company, take the time to review and understand the terms. Pay close attention to your approval date, contracted rate, documentation requirements, claims submission process, reimbursable CPT codes, diagnosis codes, and other important details. Knowing what you can and cannot bill for is essential to avoid issues later on.

Setting Up Financial Policies and Consents

Develop clear financial policies and consents to ensure your clients understand their payment responsibilities. Outline how much the client will be charged, when they will be charged, and what happens if they don't pay. Explain whether you accept insurance, what insurance you accept, and if you provide out-of-network services.

Developing Billing Processes and Technology

Decide how you will submit claims—manually, through a health plan's provider portal, using a clearinghouse, or with practice management software. Consider the pros and cons of each method and choose the one that best suits your needs. Familiarize yourself with the technology and set up processes to streamline your billing workflow.

Understanding Client Eligibility and Benefits

Before billing clients and insurance, it is crucial to understand your client's eligibility, benefits, co-pays, and prior authorizations. Verify your client's insurance coverage, active plan, and whether the planned services are covered by their plan before each visit. This step helps prevent claim denials and ensures a smoother billing process.

Submitting and Tracking Claims

Submit your claims in a timely manner, either electronically or on paper. Keep track of your claims and their status to ensure they are processed and paid promptly. Most insurance companies have deadlines for filing claims, so establish a regular claims filing schedule to avoid missing submissions.

Getting Paid

Understand the payment process and how long it typically takes to receive funds. You may receive payment through paper checks or electronic transfers, along with documentation explaining the claims status and payment amount. Stay organized and follow up with the insurer if payment is delayed.

Getting credentialed with insurance companies

Make a List of Preferred Insurance Companies: With numerous insurers in the United States, it is advisable to select the largest insurers in your area. Consider their reputation, reimbursement rates, and ease of credentialing. Consulting with other therapists about their experiences with specific insurers can provide valuable insights.

Apply to Join the Insurer's Provider Panel: Most insurers offer an online application process, which is the first step to becoming part of their provider network. After submitting your application, you will typically receive a CAQH (Council for Affordable Quality Healthcare) number, allowing you to proceed to the next step.

Complete the CAQH Application: The CAQH application is a comprehensive form that collects and maintains all the information required for credentialing by insurance companies. You will need to provide various details, including college transcripts, training site information, licensure information, and malpractice insurance policies. The process can be tedious, so ensure you have all the necessary information before starting.

Follow Up with Insurers: The credentialing process can take several months, and following up is essential. Contact each insurer at regular intervals to check the status of your application and provide any additional information they may require. This proactive approach helps identify and resolve any potential issues promptly.

Maintain Quarterly Re-Attestation: Once your CAQH application is accepted, remember to re-attest to the information on a quarterly basis. Keep an eye out for notices from CAQH to ensure you don't miss any updates and maintain your credentialed status.

By following these steps, therapists can successfully navigate the credentialing process with insurance companies, enabling them to bill insurance directly and provide a more seamless experience for their clients.

Filling insurance paperwork

Filling out insurance paperwork can be a tedious and time-consuming process, but it is a crucial aspect of running a private practice. Here are some tips to help you navigate the process:

Understanding the Basics

Before you begin filling out insurance paperwork, it is essential to understand the different options available to you as a private practitioner. You can choose to become an in-network provider by joining an insurance panel or opt to be an out-of-network provider. In-network providers have a contract with the insurance company and agree to provide services at a set rate. Out-of-network providers, on the other hand, do not have a contract with the insurance company and can set their own rates, but the reimbursement process may be more complex.

Choosing the Right Insurance Panels

If you decide to become an in-network provider, carefully consider which insurance panels to join. Evaluate factors such as the insurer's market share in your area, your target client population, the credentialing requirements, reimbursement rates, and the ease of working with the insurance payer. Joining the right insurance panels can help you attract more clients and ensure a smoother reimbursement process.

Gathering the Necessary Information

When filling out insurance paperwork, you will need to provide detailed information about your practice and yourself as a therapist. This includes your provider information, such as your name, business name, contact information, and license numbers. You will also need to provide information about your client, including their name, contact details, and insurance information. Additionally, be prepared to provide transcripts, training information, licensure information, and malpractice insurance policies.

Understanding the Requirements

Different insurance companies may have varying requirements and forms that you need to fill out. Familiarize yourself with the necessary forms, such as the CAQH (Council for Affordable Quality Healthcare), which is used for credentialing by insurance companies. Other common forms include the HIPAA Privacy Forms, Notice of Privacy Practices, Patient Demographics, and Telehealth Consent Form. Each form will have specific sections that you need to complete, such as client information, service details, and reimbursement information.

Staying Compliant

It is crucial to ensure that your insurance paperwork complies with legal and ethical standards. Review the laws and regulations specific to your state and seek attorney-approved forms to minimize legal risks. Additionally, be mindful of the "No Surprises Act," which requires therapists to provide a Good Faith Estimate (GFE) to clients before commencing services. This estimate outlines the expected costs and helps clients understand their financial responsibilities.

Seeking Support

Filling out insurance paperwork can be daunting, especially for those new to private practice. Consider seeking support from billing professionals or utilizing resources like the Private Practice Startup platform, which offers attorney-approved forms and guidance. Additionally, consult with your peers and local therapists who have gone through the process and can provide valuable insights and advice.

Deadlines and payment schedules

Therapists are generally entitled to reimbursement within 30 days. However, coding errors can cause delays, so it's important to monitor each bill sent out. If payment is not received within 30 days, it's recommended to follow up with the insurer. To expedite insurance payouts, it's beneficial to discuss insurance policies with clients, verify coverage and reimbursement rates, and request notification of any changes in insurance providers.

Additionally, it's crucial to establish and communicate policies for instances when insurance denies a claim, such as clarifying the client's financial responsibility. Familiarity with specific insurer policies is also essential, including requirements for pre-authorization, specific condition diagnoses, and contact information for billing inquiries.

Getting insurance payouts

Collect Insurance Data

Firstly, it is important to collect all the relevant insurance data from your patients. This includes confirming payment responsibility and understanding the billing practices of different providers and policies. Most policies will include a co-pay for office visits that the patient is responsible for. However, it is also important to note that certain providers or policies will cover different services in different ways. As a healthcare provider, you can work the system to ensure that services are rendered, coded, and billed to get the maximum payment from insurance providers, reducing the financial burden on patients.

Accurate Information

Whether you perform medical billing and coding in-house or outsource it, it is crucial that the information provided is accurate to ensure full reimbursement. This includes ensuring that patient information (name, address, policy number, etc.) is error-free, as well as providing accurate diagnosis and treatment information. Insurance providers will be looking for any slight error that allows them to deny claims, so it is important to be familiar with what each provider and policy covers. Make sure that the terminology for diagnosis and treatment precisely matches the billing and coding requirements.

Follow Up and Reporting

If claims are delayed, only partially paid, or denied, you need to follow up to understand the reason. You can do this yourself or ask your medical billing and coding service provider to do it for you. Most services will automatically follow up if claims processing takes longer than a certain time limit. However, you should also choose a service that provides regular reports on your claims to help you predict when you will be paid and ensure that your service is doing everything they can to get you paid promptly.

Implement Quality Technology

Using quality technology and software can increase clean claims, streamline your billing workflow, and maximise reimbursements. Look for software that supports swift claim submission and helps you stick to each payer's billing schedule. The right software will allow you to file claims electronically to all of the top insurance companies. Additionally, find software that includes built-in claim denial and rejection follow-up features, as well as credit card integration to maximise client payments on remaining balances.

Benefit Verification

It is important to ensure that your clients understand their coverage to optimise revenue. Mental health billing software should come with electronic benefits verification to make sure you can get paid. Choose a software vendor that cares about your success and has your best interests in mind. Look for a dedicated account manager who is accessible and a team of billing experts who can quickly identify and solve problems.

Submit Claims

Regardless of whether your patient, the insurance company, or both are responsible for paying, you will need to submit a claim to the insurance company. This allows the insurance company to track how much a patient has paid toward their deductible and process any part of the allowed amount that they owe. If your patient is responsible for any amount, you will need to collect the payment from them while they are in your office or bill them after the session.

Frequently asked questions