Understanding Insurance Billing Procedures Post-Sale: A Guide For Psychotherapy Corporations

Billing insurance companies for psychotherapy services can be a challenging and time-consuming task, but it is crucial for the financial health of mental health practices. The process involves several steps, from credentialing with insurance companies to using correct procedure codes and submitting claims electronically or via paper forms. Mental health professionals must navigate complex insurance industry rules and regulations to ensure prompt and accurate reimbursement for their services. While billing can be outsourced or handled manually, understanding the basics of therapy billing and claims is essential for any clinician. This includes gathering client information, such as full name, date of birth, and insurance details, as well as selecting the appropriate procedure codes for each session. By following these steps and staying organized, mental health providers can maximize their reimbursement rates and focus more on helping their clients.

Understanding the credentialing process

The credentialing process is a formal process that ensures patients receive the highest level of care from healthcare professionals who have undergone scrutiny regarding their ability to practice medicine. Credentialing is the first step to putting a physician to work at a facility. It is how employers ensure the applicant is who they say they are and that their credentials are legitimate.

The process includes verifying information such as:

• Education and training
• Specialty certificates
• Licensure
• Experience
• Competency
• Judgement

This is done through primary source verification (PSV), where the organisation doing the credentialing reaches out to the original source to verify the information.

The credentialing process can be manual, but this is time-consuming and prone to errors. Credentialing software can help to reduce errors and speed up the process.

Who is involved?

During the credentialing process, the provider will interact with the medical staff services office at the facility where they will be working. The following people may also be involved, depending on the size of the facility:

• Credentialing committee members, including facility leaders, human resources professionals, and risk management leaders
• Medical executive committee members
• CEO or governing board

The following information is typically required for credentialing:

• Social security number
• Demographic information (ethnicity, gender, citizenship, languages spoken)
• Education and residency information
• Specialties and patient focus
• Information about the healthcare facility
• Medical licenses
• Drug Enforcement Administration (DEA) ID number
• Malpractice insurance carrier and case information
• Board certification
• Work history
• Health documentation
• Activity or procedure logs

There is no standard timeframe for the credentialing process. It can be completed within 90 days, but experts suggest giving yourself 150 days. The process can take even longer if serious issues arise. In some cases, it can take up to six months or more.

The credentialing process may be delayed if:

• The applicant does not provide needed information in a timely manner
• References are unresponsive
• There are past issues or concerns that have not been disclosed

CPT codes and billing guides

CPT, or Current Procedural Terminology, codes are an integral part of the billing process. They are five-character numeric or alphanumeric codes that describe the procedures and services performed by a healthcare provider on a patient. They are used to tell the insurance payer what procedures the provider would like to be reimbursed for. CPT codes are also used to track important health data and measure performance and efficiency.

There are three categories of CPT codes:

• Category I: The most common and widely used set of codes, describing most procedures performed by healthcare providers in inpatient and outpatient offices and hospitals.
• Category II: Supplemental tracking codes used for performance management.
• Category III: Temporary codes that describe emerging and experimental technologies, services, and procedures.

When billing insurance, it is important to use the correct CPT codes to avoid delays in payment, audits, or removal from the insurance company's panel. Here are some examples of CPT codes for psychotherapy:

• 90791: Exclusive to the first appointment held with a client
• 90832: 16-37 minute session
• 90834: 38-52 minute session
• 90837: 53+ minute session
• 90839: 60-minute crisis psychotherapy
• 90847: 50-minute family psychotherapy when the primary client is present
• 90849: Multiple-family group psychotherapy
• 90853: Group psychotherapy
• 96132: Neuropsychological testing services

In addition to CPT codes, there are also HCPCS (Healthcare Common Procedure Coding System) codes, which are used to bill Medicare, Medicaid, and other third-party payers. HCPCS Level I codes are based on CPT codes and are used for services and procedures offered by healthcare providers, while Level II codes cover services and procedures not performed by healthcare providers, such as medical equipment, supplies, and ambulance services.

When billing insurance, it is important to follow the correct procedures and guidelines, including obtaining credentialing, understanding the client's insurance plan, and submitting claims in a timely and accurate manner.

Client information requirements

When billing insurance for psychotherapy services, it is important to collect and keep track of certain client information. This ensures that claims are submitted correctly and reduces the risk of delays or denials. Here are the key pieces of client information that are typically required:

• Full legal name of the patient
• Date of birth
• Address
• Gender
• Social Security Number (rarely required)
• Phone number
• Email address
• Insurance information, including the subscriber ID with the alpha prefix, and a photo or copy of the insurance card
• Insured's information if the client is a dependent on the insurance plan
• Diagnostic/ICD-10 codes
• Service codes and modifiers for each date of service

It is also important to verify the client's insurance plan and coverage, including copays, deductibles, and whether pre-authorization is required for certain procedures. This information can be obtained by calling the insurance company or logging into their website.

In addition to client information, you will also need to provide your own practice information, such as your practice tax ID, practice location, and service provider's NPI and taxonomy code.

Keeping accurate and up-to-date client records is crucial for successful insurance billing in psychotherapy. It is recommended to double-check all information for accuracy and completeness before submitting claims to insurance companies.

Deadlines and payment schedules

Therapists who work with multiple insurers may need to juggle multiple deadlines, which can be challenging. Submitting claims promptly is essential to ensure timely reimbursement. Most insurers require claims to be submitted within a specific timeframe, known as the timely filing deadline or timely filing limit. This period typically begins on the date of service and can range from 90 days to 365 days, depending on the insurer. Claims submitted after the deadline will be denied, and the provider may lose the right to reimbursement.

To avoid delays in payment, it is crucial to select the correct billing code and ensure accurate and complete information on the claim form. The Current Procedure Terminology (CPT) codes are commonly used for mental health billing and should be selected based on the procedure and the length of the therapy session. Proper coding is essential to avoid triggering an audit, delayed payment, or removal from an insurer's provider panel.

In addition to timely filing deadlines, payment schedules also vary across insurers. Therapists are generally entitled to reimbursement within 30 days of submitting a claim. However, coding errors or other issues may cause delays, so it is important to follow up with the insurer if payment is not received within the expected timeframe.

To streamline the billing process, it is beneficial to have a clear understanding of the requirements and guidelines of each insurer. This includes knowing their specific codes, deadlines, and payment processes. Additionally, maintaining accurate and up-to-date client information, such as demographic details and insurance data, is crucial for successful and timely reimbursement.

Getting insurance payouts

Understand the Basics of Insurance Billing:

Before you begin, it is essential to understand the basics of insurance billing for therapy sessions. Familiarize yourself with the Mental Health Parity and Addiction Equity Act of 2008, which prohibits insurers from discriminating against mental health services. This means that insurers must cover mental health care to the same extent as physical health care.

Credentialing:

Credentialing is the process by which insurance companies ensure you are qualified to serve on their panel of providers. It is crucial to get credentialed with insurers to bill them directly and avoid reimbursement issues for your clients. Contact the insurance companies you wish to work with, and inquire about their credentialing process and requirements. You will likely need to provide documentation, such as your license to practice in the state, malpractice insurance, and your taxonomy code.

Choose a Billing Method:

You have a few options for handling the billing process. You can outsource it to a billing company, which can be costly but may save you time and headaches. Alternatively, you can bill manually or through the insurance company's provider portal, but this requires a good understanding of billing procedures and formats. Another option is to use practice management software that includes therapy billing capabilities, which can streamline the process.

Collect Client Information:

Accurate client information is vital for successful insurance billing. Collect the following details: full legal name, date of birth, address, gender, phone number, email address, insurance company name, ID number, group number, insured's information (if the client is a dependent), and subscriber ID. It is also a good idea to snap a photo of their insurance card for your records.

Verify Client Insurance Coverage:

Before providing services, verify your client's insurance coverage to avoid issues with reimbursement. Contact the insurance company to confirm their active insurance plan, mental health coverage, copays/coinsurance, deductibles, and any pre-authorization requirements. It is also essential to review the client's insurance plan regularly, as benefits may change over time.

Proper Coding:

Use the correct Current Procedure Terminology (CPT) codes for each therapy session. These codes depend on the type of procedure and the length of the session. Examples include 90832 for a 30-minute psychotherapy session and 90839 for a 60-minute crisis psychotherapy session. Keep in mind that CPT codes may change periodically, so refer to the American Medical Association's CPT manual for the most up-to-date information.

Submit Claims Promptly:

Submit your insurance claims promptly to avoid delays in reimbursement. Each insurance company has its own deadlines for filing claims, so stay organized and submit them within the required timeframe. Most insurance companies now require electronic submissions, so ensure you have a secure digital means of sending the claims.

Track and Follow Up on Claims:

Keep track of the status of your submitted claims. Most insurance companies will either send a paper check or use electronic funds transfer (EFT) for reimbursement. If you use a clearinghouse or practice management software, it should provide real-time updates on claim status. If a claim is denied, don't take it personally. Learn from the denial, make any necessary corrections, and resubmit the claim.

Establish Policies for Denied Claims:

Develop clear policies for handling situations where insurance denies a claim. Determine whether the client is responsible for payment in such cases and communicate this to them upfront.

Stay Organized and Persistent:

Insurance billing can be a complex and time-consuming process. Stay organized by maintaining detailed records, using practice management software, and establishing efficient workflows. Don't be afraid to persistently follow up on claims and seek clarification from insurance companies when needed.

By following these steps and staying diligent, you can increase your chances of receiving timely insurance payouts and minimize disruptions to your practice.

Frequently asked questions