Navigating the Insurance Maze: The Therapist's Complete Guide to Working with Insurance - And Whether You Should, by Barbara Griswold, Licensed Marriage and Family Therapist
Navigating the Insurance Maze: The Therapist's Complete Guide to Working with Insurance - And Whether You Should, by Barbara Griswold, Licensed Marriage and Family Therapist
Navigating the Insurance Maze: The Therapist's Complete Guide to Working with Insurance - And Whether You Should, by Barbara Griswold, Licensed Marriage and Family Therapist
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Why You Need to Start Talking Like a Nurse:
What You Need to Know About Parity and Medical Necessity

By Barbara Griswold, LMFT
(December 1, 2011)

First, a little background: When I first opened my practice 21 years ago, if a client was lucky enough to have medical insurance, it often didn't cover psychotherapy. With each passing year, more plans covered therapy, but usually imposed higher copayments and yearly visit limits.

In 1996, California passed a limited parity law, a milestone in the effort to eliminate this kind of double standard. The law required most insurance plans to provide coverage for mental health and substance abuse treatment that was at least equal to ("at parity with") the plan's medical coverage. However, the parity law was limited to clients who had one of the following "parity" diagnoses: Major Depression, Bipolar Disorder, Schizophrenia, Schizoaffective Disorder, Obsessive Compulsive Disorder, Panic Disorder, Bulimia, Anorexia, Autism/Pervasive Developmental Disorder, or Serious Emotional Disturbances of Children.

What changed: In 2010, the Mental Health Parity and Addiction Equity Act (MHPAEA) went into effect. Superseding California's parity law, this Federal Act mandates — for ALL mental health and substance abuse diagnoses covered by the plan — that coverage be at least equal to that of the plan's medical benefit. Plans can no longer impose limits on mental health visits if no such limit exists for medical visits. There can be no higher deductible or copayment for mental illness or substance abuse treatment. And if a plan covers out-of-network medical care, it must cover out-of-network mental health care. Of course, there are exceptions. The Act doesn't apply to individual plans, or employers with less than 50 employees. In these cases, the state parity law may still come into play.

Why this matters to us: Now that most plans can no longer impose annual session limits, many plans are taking advantage of a loophole still available to them to restrict treatment, known as "medical necessity." Even if a member has coverage for unlimited sessions, the plan may refuse to cover ANY service it believes is not medically necessary. This is true for both in-network and out-of-network providers, and regardless of the plan type.

To determine medical necessity for treatment, many plans now require periodic written or telephonic treatment updates so that care can be reviewed by case managers. For example, most Anthem Blue Cross of California accounts now require that providers complete an Outpatient Treatment Report (OTR) after 12 sessions.

What we need to do: To advocate on our client's behalf, we need to learn to speak the language of medical necessity when talking to case managers or filling out treatment reports. You may ask the plan for their Medical Necessity Criteria (often on their websites), but typically they are looking to see that:

  • There is a known or suspected DSM diagnosis (not just a V-code).
     
  • Treatment must alleviate some measurable medical symptom (such as insomnia, anxiety or depression). Therapy can't be solely for personal growth, career issues, self-esteem, communication, or improving relationships. Avoid treatment plans that focus on feelings awareness, healing the inner child, or finding meaning in life.
     
  • The symptoms must have decreased the client's level of functioning. A DSM Axis V GAF (Global Assessment of Functioning) score above 40 and below 69 is often required for outpatient therapy.
     
  • The problem seems resolvable in therapy.
     
  • Treatment is believed to be the most appropriate type, level, and length needed. Clients reaching therapeutic plateaus may be considered more appropriate for referral to community support, while others may need more intensive treatment.
     
  • The client is making some progress, or at least being stabilized to prevent relapse or deterioration.
     
  • The client must be motivated, participating, and following recommendations.
     
  • When substance abuse is diagnosed, an evaluation has been done.
     
  • Medications are being used, where indicated, or documentation is made of why they are not.
     
  • You are coordinating care with other treating providers and physicians.
     
  • When working with a child, your treatment plan typically must include family therapy, unless contra-indicated.

So, some tips for talking to a plan: If your care is ever reviewed, here are some things to keep in mind:

  1. Imagine you work in a hospital. Learn to describe and record your client's observable symptoms, progress, and your care in a very "medical model" way.
     
  2. Be specific, noting symptom severity and frequency, and scores on even simple diagnostic tests. Look up the diagnosis in the DSM, and use applicable terminology (e.g. "hypersomia"). Identify symptoms and how they have negatively impacted the client's "Activities of Daily Living" (ADLs), such as work, family, friendships, finances, and self-care.
     
  3. Describe how treatment will reduce impairment, or prevent relapse or hospitalization. What are you doing in session or what homework are you giving to reduce symptoms? Tie these interventions to your goals. Remember: The goal need only be to return the client to a baseline level of functioning, not complete symptom elimination.
     
  4. Make sure goals are measurable, realistic, and consistent with the diagnosis. Avoid vague goals such as "help identify feelings, and support through divorce," which does not clearly spell out the symptoms being treated. Try to quantify goals. For example, instead of "client will sleep better" you might say "reduce reliance on sleep medication to no more than two times per month."
     
  5. Identify any progress, however small, toward symptoms reduction or goals.
     
  6. Be prepared to discuss why your chosen modality (individual/couples/family/group) is the most cost-effective way to treat the client's symptoms.
     
  7. Be ready to discuss referrals you have made, and coordination of care with treating professionals (or be ready to explain why these did not occur).
     
  8. The plan may want you to discuss your treatment plan with your client, and for you to do periodic check-ins.
     
  9. Above all, don't take his/her questions personally, and don't be defensive. They are just doing their job. Imagine you just know more about the case, and need to educate the case manager about the details.

To stay current on the ever-changing world of insurance subscribe now to my free monthly insurance e-mail newsletter.

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Getting Paid More: Are Raises Possible?

By Barbara Griswold, LMFT
(September 21, 2011)

Managed care reimbursement is the biggest source of provider complaints. Yet most providers have never asked for a raise, assuming they would be unsuccessful. So you might be surprised to learn that providers are often able to negotiate raises – even in a recession. Recently, I was able to negotiate a raise for myself, and I have been happy to be able to help several therapists to get raises for themselves. So why not try it – what have you got to lose?

Steps for Requesting a Raise:

  • Call the insurance plan's Provider Relations Department and discuss your request. Be prepared to defend why you feel you deserve a raise.
     
  • You may be asked to write a letter. Include how long you have been with the network, whether you are a high-volume provider, and your unique specialties or skills. These special services may include the ability to conduct therapy in another language, to work with the hearing impaired, offer crisis stabilization/emergency care, employer training or lectures, Critical Incident Stress debriefings, can see inpatient clients pre- and post-discharge, treat kids, treat Autism/ADHD, veterans, offer weekend hours, or if you are a Certified Employee Assistance Professional (CEAP) or Substance Abuse Professional (SAP). A fee above the standard rate might also be considered if an employer specifically requests your inclusion, if you work in an underserved area, or if you are part of a group practice that can offer a continuum of services. Bottom line: Let them know why you are worth paying a bit more to keep.
     
  • Name the fees you are requesting for each service you provide (use CPT codes).
     
  • Avoid making resignation threats or blackmailing them. You may, however, hint you are unsure if you can continue at the current rate.
     
  • Find out where to send the letter, whether you can fax it, and to whom you should address it.
     
  • For assistance crafting your raise request, feel free to contact me at barbgris@aol.com.

If you are unsuccessful, try again in six months. You may consider asking if there is anything you might do to earn a fee increase.

Why can't my professional organization lobby on my behalf for better fees? Many providers wish their professional organizations would lobby managed care plans for raises on their behalf. However, they can't. Self-employed therapists cannot collectively bargain – only employees who hold non-managerial positions can organize a union to collectively negotiate. Self-employed therapists are independent contractors, and cannot boycott, strike, threaten as a group to resign if rates are not increased, or fight together for a minimum reimbursement. This is considered "price fixing" or "restraint of trade," and violates the Sherman Antitrust Act. To land you in hot water, the plan would need only to establish that there has been some sort of "contract, combination, or conspiracy" between providers in an effort to collectively bargain and control rates. Such an agreement does not need to be in writing: An informal discussion between therapists at a social function expressing dissatisfaction about a plan's reimbursement rates, followed by a mass withdrawal of therapists from that plan could support a successful antitrust prosecution. This could result in fines up to $350,000 or three years' imprisonment, or both.

To stay current on the ever-changing world of insurance subscribe now to my free monthly insurance e-mail newsletter.

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Magellan to take over Blue Shield Contract, Recruiting California Providers

By Barbara Griswold, LMFT
(April 20, 2011)

You may know that in California, most of Blue Shield's mental health services have been handled by U.S. Behavioral Health (aka USBH or USBHPC). This meant that even if you were a Blue Shield provider, your services might not be covered unless you were a USBH provider. But many providers were shut out, since USBH has not been accepting new providers in many areas.

Game change: As of Jan. 1, 2012, Magellan Behavioral Health's California company, Human Affairs International of California, will manage the behavioral health and EAP benefits for 1.9 million Blue Shield of California members.

To handle this huge influx of new Blue Shield members, Magellan is aggressively seeking new California providers for both their mental health and EAP networks.

This means if you want to continue (or start) seeing those Blue Shield of California clients, you may want to consider joining Magellan.

To stay current on the ever-changing world of insurance subscribe now to my free monthly insurance e-mail newsletter.

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"If I Accept Insurance, Do I Have to Deal with HIPAA?"

By Barbara Griswold, LMFT
(February 24, 2011)

At my workshops, I have been surprised to find that many therapists avoid getting involved with insurance because they don't want to deal with HIPAA. But let's burst this myth right here: Taking insurance does NOT have to mean dealing with HIPPA. But I can also tell you that in my opinion, HIPAA is not a hassle.

But let's start at the beginning: HIPAA (the Health Insurance Portability and Accountability Act) was passed (in part) because of concerns about the privacy of medical information, especially in light of the increasing use of computers by insurance plans and medical practices. While it is not within the scope of this article to cover all the ins and outs of HIPAA regulations, I want to address a few general FAQs as they relate to taking insurance:

"Do I have to deal with HIPAA?" According to David Jensen, staff attorney at the California Association of Marriage and Family Therapists, you are a "HIPAA covered entity" and MUST deal with HIPAA if you exchange client information with a health plan electronically (via e-mail or Internet), such as if you visit a plan's website to submit claims, check eligibility/benefits, request authorizations, view Explanations of Benefits, or if you receive/send client info in an e-mail from/to a plan. You also must be HIPAA compliant if a billing service or claims clearinghouse does electronic transactions for you.

"So if I don't use a computer in this way?" You DO NOT have to deal with HIPAA if you don't deal at all with insurance claims, or you give invoices to your clients to submit to their plan, or you only submit paper claims by mail or fax and you have no one submit claims electronically on your behalf. I know many therapists who deal with insurance and avoid HIPAA simply by avoiding these electronic transactions.

"What if I use the computer to e-mail clients?" Not the same thing. HIPAA has to do with revealing or exchanging a client's private health information with a third party (in this case, the insurance plan).

OK, so if I do became a "covered entity," what would I need to do?" It's probably easier than you think. Here are a few things you'll need to do:

  • Learn about HIPAA compliance. Attend a course or read a few articles.
     
  • Give all clients (even self-pay) a copy of a HIPAA "Notice of Privacy Policies," and have them sign a simple Acknowledgement saying they received it. Get a Notice from your professional organization, or from any HIPAA course or manual.
     
  • Follow some common-sense HIPAA security rules. Provide computer security, including virus protection, backup, firewalls, and passwords. There are also some rules about your paper records and fax.
     
  • Get your National Provider Identifier (NPI), which is used by all health plans to identify you. It's free and easy to get. The NPI does not replace your Tax ID Number (TIN) on claims. Any health provider can get one — applying does not automatically make you a covered entity.

"But do I really have to?" One day all of us will likely be required to deal with HIPAA. As health plans become more electronically dependent, they may one day require electronic submission of ALL claims. And HIPAA and NPIs may become the standard of care — if not legally required — for all providers. But for now, you still have the choice.

Wish you had a quick-reference insurance "bible"? Visit my order page to purchase your copy now. Or contact me to set up a consultation to address any questions you have about working with insurance.

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Health Care Reform Update: Key Provisions Take Effect

By Barbara Griswold, LMFT
(September 24, 2010)

On September 23, 2010, key provisions of the historic health reform law (Affordable Care Act) took effect, offering better insurance coverage for most Americans. A few of the big changes follow:

  1. Children under the age of 19 can no longer be denied coverage based on a pre-existing medical or mental health condition (adults won't get this benefit until January 2014).
     
  2. If a parents' plan provides coverage for dependent children, it now must cover children up to age 26 (even if the children are married, live outside the home, or are financially independent).
     
  3. Plans can no longer limit the dollar amount of yearly — or lifetime — benefits.
     
  4. Private plans now must cover free preventive services, including depression screening.

Of course, there is always the fine print and exceptions, some of which are below:

  1. These provisions won't take effect until the policy renews for the first time after September 23, 2010.
     
  2. Plans can limit spending for services considered "not medically necessary."
     
  3. Plans may only be required to provide free preventive services through a network provider.
     
  4. Plans do not have to offer dependent coverage if a young adult is eligible for their own coverage.

Learn more at the government's health reform website (www.healthcare.gov), or for more about coverage for dependent children, go to www.gettingcovered.org.

To get the manual that answers all your insurance questions, click here, or to set up your insurance consultation with Barbara, click here.

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Do You "Accept" Insurance?
Avoiding Frustration When Working With Insurance

By Barbara Griswold, LMFT
(September 24, 2010)

I recently spoke with a lovely colleague who told me she did not accept insurance because she didn't like the limitations, and worried plans would tell her how to do her job. I hear this valid concern often — a fear of losing control of treatment once insurance gets involved.

I admired her desire to maintain her independence and integrity, yet told her, "insurance plans don't tell me how to do my job. I provide the same care to my insurance clients as my private-pay clients. However, plans may say what they will and won't cover."

I told her I think of insurance in the same way that I think of my parents offering to pay for my wedding. They may say, "If we're paying, this is what we will pay for, and this is what we won't." But I retain the choice to say "never mind, I'll just pay for it myself," or "OK, I accept what you'll pay for, and I'll pay out of pocket for whatever else I want that you won't cover." The same is true when speaking about therapy.

A similar example would be that of a limited scholarship to college: Should we choose not to accept scholarship money because it doesn't cover the entire tuition?

I've found to avoid the frustration inherent when working with insurance, it has been helpful to make a few mental shifts:

  1. I help clients look at insurance as a means to help them partially finance treatment, not as an entitlement that will pay for every dollar of every session they may desire.
     
  2. I try to be mindfully grateful for whatever coverage the client has, instead of focusing on it's limitations.
     
  3. I remind myself that clients may continue privately after their coverage ends, and refer full-fee clients.
     
  4. I regard accepting insurance as one way to make my work accessible to clients of all socio-economic backgrounds.
     
  5. I think of the discounted insurance rate as including an imaginary referral fee, that pays for the marketing the plans do on my behalf.
     
  6. And I work daily to unhook myself (and my clients) from making decisions about treatment based on coverage.

To get the manual that answers all your insurance questions, click here, or to set up your insurance consultation with Barbara, click here.

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Don't Take No for an Answer: 10 Tips for Fighting Denials

By Barbara Griswold, LMFT
(April 17, 2010)

You've received a denial from an insurance plan. You think, "Why bother fighting? It takes too much time, and I won't win." But in my experience, if you follow the tips below, your chance of overturning the denial can be quite high.

  1. Start with a call to Claims or Customer Service. While some errors can be quickly identified, allow at least 20 minutes for the call.
     
  2. If the denial reason was "no pre-authorization," ask the plan to back-date one. If they will, resubmit the claim with a note including the new auth number. If they won't, appeal.
     
  3. If the denial involves a treatment issue, put together a clinical argument for how the sessions are medically necessary, are the best type of treatment, and prevent more intensive treatment. Outline your treatment goals/plan. Review the plan's Medical Necessity Guidelines (often in the Provider Manual, on the plan's Web site).
     
  4. Avoid defensiveness, threats, or overly dramatic predictions of consequences if your appeal is not granted. Imagine that the plan simply needs some additional clinical information to see it your way.
     
  5. If needed, ask to speak to a supervisor (or even the plan's Clinical or Medical Director). They have more power to make exceptions.
     
  6. If the plan requests repayment, delay payment. Call the plan (or financial recovery service) and have your intended appeal documented.
     
  7. If still unresolved, the client can ask his employer's Benefits Manager to intervene on his behalf. Because employers pay the premium, the plan may be more responsive when the Benefits Manager calls.
     
  8. Submit an appeal. This is a written notice challenging a denial or requesting an exception to the plan's policies. Even out-of-network providers can appeal, or if it was your error that led to the denial. A sample appeal letter can be found in my book (click here for info). Contact the plan for details about its appeal process and filing deadlines. If treatment is the issue, focus on why the treatment is the most clinically (and cost) effective. Include copies of relevant documents. Your client can write the plan and (at no charge) receive information used to review the initial claim/treatment request — this can assist in your appeal. Ask for an expedited appeal if you need immediate approval to continue necessary treatment.
     
  9. Get help. Helpful appeal resources include a non-profit patient advocate such as the Patient Advocate Foundation (800-532-5274, www.patientadvocate.org), your professional organization, or hire a professional insurance consultant (contact me for names).
     
  10. Appeal to your state's Department of Insurance or Department of Managed Health Care. Take this step if your appeal has been denied or ignored. Your appeal has a good chance of being supported: Of the mental health Independent Medical Reviews performed by the California Department of Managed Health Care in 2007, 47% overturned the denial by the health plan.1

Remember to keep a communication log, with names, dates, and conversation details.

And don't worry, you aren't being codependent when you fight for your clients. Most professional therapist associations have ethical standards that require members to advocate for the care they believe will benefit clients. Assisting a client with an appeal may even be required by state law.

For more details about dealing with denials, and more tips for successful appeals, check out my book or contact me to set up a consultation.

1 - "California Department of Managed Health Care 2007 Independent Medical Review Results by Health Plan Report Definition," retrieved 4/17/10 from http://www.hmohelp.ca.gov/library/reports/complaint/2007.pdf.

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An Update: The New Parity Law and What it Means for You

By Barbara Griswold, LMFT
(February 27, 2010)

Back in November of 2008, I told readers about the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA). Well, it just went into effect, so here's an update on how your life may change because of it.

FIRST, A REVIEW: WHAT IS THE LAW ABOUT? The MHPAEA requires health plans to provide coverage for mental health and addiction treatment that is equal to ("at parity with") coverage provided for the treatment of physical illnesses covered by the plan. It strengthens and expands previous parity laws, which were very limited in scope. It is estimated that approximately 1/3 of Americans will now have better coverage. Group health plans with more than 50 employees will no longer be able to impose limits on inpatient days or outpatient mental health visits if no such limit exists for medical visits. These plans won't be able to require higher deductibles or copayments for mental illness or substance abuse treatment than the plan imposes for medical treatment. In addition, if a plan allows your client to go out of their network of providers for medical care, it must also offer out-of-network coverage for mental.

HOW WILL THINGS CHANGE FOR MY CLIENTS?
1. For some clients, their deductible may be waived or reduced, and/or the co-payment may be lower, meaning they may be able to see you more frequently — and longer — than they otherwise could have.
2. They may now also be eligible for unlimited sessions.
3. Some clients will have out-of-network coverage when they previously did not, or better out-of-network coverage.

THE FINE PRINT?
1. The MHPAEA does not require a plan to cover specific illnesses, but applies to all diagnoses that a plan covers.
2. The MHPAEA supersedes state parity regulations if the state regulations are more limited.
3. Individual plans and businesses with 50 or fewer employees are exempt. EAPs are also expected to be exempt.
4. The MHPAEA doesn't require coverage to be "good" — it just needs to be equal to medical. Therefore, a client can still have a high deductible or copay or limitations, if their medical coverage does.
5. A plan is not required to cover any particular provider license (ex. MFTs or LPCs).

THE MOST CONCERNING CATCH? While large plans that have no limit on medical visits can no longer limit mental health or substance abuse visits, they retain the right to cover only "medically necessary" visits. Therefore, I think we will see plans making more of an attempt to review our treatment according to their criteria for medical necessity. This may involve more preauthorizations and data gathering, sometimes even for out-of-network providers. I don't think it is a coincidence that Anthem Blue Cross of California announced that many of their plans will now require authorization after the 12th visit. Blue Shield of California recently notified providers in one of their plans (the Federal Employee Program PPO) that they must now must get preauthorization, and — beginning March 22nd — submit an Outpatient Treatment Plan prior to the third visit.

BE POSITIVE! But, before we get too pessimistic about paperwork treands, let's take a moment to enjoy this. Something truly historic and wonderful came out of Washington! At a time when the lack of progress on health care reform is pretty depressing, it is nice to remember that — not that long ago — our representatives were able to get something pretty important passed.

For more details on parity and how it will affect you, I recommend this helpful article: http://www.apapracticecentral.org/news/2008/wellstone-domenici.aspx

To get the manual that answers all your insurance questions, click here, or to set up your insurance consultation with Barbara, click here.

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Becoming a Network Provider:
Selling Yourself to Insurance Companies

By Barbara Griswold, LMFT
(November 15, 2009)

I enjoy telling therapists that when I joined my first insurance plan 17 years ago, it seemed the only condition for joining was a pulse. Many panels required little more than an application and resume. Those days are gone. In many areas of the country, insurance plans just have more applications than they need, so they are often closed to new providers. Since it is expensive to maintain a large provider network, it is in the plan's best interest financially to maintain the fewest number of providers. However, they are also required to maintain a minimum number of providers with a variety of specialties to serve their members in any area.

So, let's say you want to join a provider panel. Where do you start?

• Must you wait two years? It's true that many plans say they won't accept you until you have been licensed two (or more) years. However, don't let this stop you from applying. A plan may land a new employer account and need to add providers quickly and unexpectedly, and may dig into their application file. Also, exceptions may be made if you have a needed skill, specialty, language fluency, location, etc.

• Get a list of insurance plans. Your professional organization (ex. CAMFT) or state Department of Insurance may be able to provide you with such a list. Psychotherapy Finances (www.psyfin.com), a must-have monthly newsletter for therapists, has a section alerting readers to insurance panel openings. Also, contact Fran Wickner, MFT, (www.franwickner.com) for a list of 60 plans and their contact information, available on mailing labels.

• Develop a letter of interest and resume that is specifically targeted to insurance plans, and highlights the kind of experience and specialties you have that a plan would be looking for. (For help creating a dynamic targeted resume and interest letter that will make plans take a second look at you, click here and we'll set up your personal phone consultation).

• Use your time effectively. While you can call each plan or visit their Web site to see if they accept online applications, if you want to limit the time you spend on this project, do a blanket mailing, submitting your resume and letter of interest by mail to all plans on your list, even if they say they are full. If you are sent an application, you can ask any questions you may have at that time.

• If you are told the network is closed, or get no response, call the plan and try to sell yourself. Find out what needs they have in your area that might make them consider/reconsider your application (subletting a second office for a few hours each week in an underserved area? Leading a group? Getting CISD training?

• If turned down, reapply every six months. Eventually, through attrition or an increase in the plan's membership, there will be openings on the panel, and your efforts will pay off.

• Keep a log with dates of actions you took, phone calls made, names of people you spoke with, and their advice.

• If you get frustrated, remember why you are doing this. Insurance referrals can account for thousands of dollars of income to your practice, and help keep your practice full.

For more advice about what plans are looking for, what to highlight in your cover letter, how to answer application questions, and all other questions about insurance, click here to purchase my insurance manual, Navigating the Insurance Maze, or to set up your consultation.

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The Top 10 (Mostly Preventable) Reasons Your Claim Could be Denied

By Barbara Griswold, LMFT
(July 10, 2009)

Managed care plans report these common situations that lead to claim denials (notice how many of them could be avoided by asking the right questions at the start of treatment):

1. Diagnosis issues. One of the biggest issues tripping up therapists is failure to use the full number of digits required for a diagnosis. Most commonly, five digits (two to the right of the decimal) are required, though some diagnoses have only three or four digits. Most plans require an Axis I or II diagnosis (except for EAPs, which allow V-code diagnoses). And be sure to use the diagnosis code — don't simply write the name of the diagnosis.

2. No authorization on the date of the session. Be sure to get necessary authorizations, keep track of expirations, and take care not to exceed the number of allotted sessions.

3. Yearly session limit has been exceeded. Be sure you keep track of the number of sessions used. Remember that not all plans run on the calendar year — for example, some give clients 20 sessions over a 12-month period from the start of treatment.

4. Wrong claims address. Always call the plan in advance to check the claims address. Never trust the address on the health plan card, one a client gives you, or even the one given by the automated phone service at the health plan, as it is often not the one for mental health claims.

5. The claim was incomplete or illegible. If you submit paper claims, review them carefully to be sure you fill out all necessary boxes, and work on your clear block printing!

6. Wrong codes. You may have used a CPT code for a type of service other than the ones that were authorized, used a code they do not cover, or used a non-existent code. Or you may have used the wrong Place-of-Service code. You may have written "O," "OV," "OFF" or "Office" to stand for office, instead of the required "11" for "office."

7. The claim was late. Some plans require the claim be submitted within 60 or 90 days. If your claim is denied for this reason, the plan may not allow you to bill the client.

8. Incorrect claim form. Most plans require the newest version of the CMS-1500 forms (to purchase blank claim forms, click here), but some plans (including some EAPs) require their own claim forms.

9. The claim is being held, or "pended." Frequently, a claim is pended awaiting information from the member about "Coordination of Benefits." The insurer wants to find out if the client is covered by another plan.

10. The client was not eligible, or has a "pre-existing condition" exclusion. New employees sometimes have a period of time before their coverage "kicks in." Or if the client had a medical problem which existed at the time she enrolled, the plan may deny all claims pertaining to this medical problem for a certain period. For employer-provided coverage, the exclusion period is typically limited to 12 months.

Have insurance questions? Want more practical tips? Purchase Barbara's insurance manual complete with sample forms and line-by-line claim form instructions (click here) or schedule a consultation with Barbara (click here).

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Taking the Pain Out of Billing:
Office Ally is a True Therapist's Ally

By Barbara Griswold, LMFT
(May 11, 2009)

It's unusual that I come across a service that I think is so terrific that I would write an article about it, but get ready for the exception.

Office Ally is a tool that ANY therapist can use to submit a claim to ANY insurance company (this includes Medicare, Medicaid/MediCal, and TriCare/Champus). It's easy, fast, and best of all, it's free.

You don't need to be a plan provider. You can submit just one claim. Or you can submit a whole bunch of claims, and OA will sort them, convert them to a HIPAA-compliant format, and submit them electronically to the proper insurance plan. There is no need to purchase software. You need nothing more than an internet connection.

Office Ally offers three options for claims submission. The first is a free online entry tool where you type data into a blank claim form on the website. You can store client and provider information so you do not have to re-type the same information each time you bill. If you'd like something more comprehensive, Office Ally offers "Practice Mate," a complete (and free) web-based practice management and accounting system, which can track sessions and payments, create client statements, and can even schedule appointments. And finally, if you already have your own practice management software which allows you to print claims, Office Ally can transmit your claims electronically. Once your software has created an image of your claims, simply upload these files at the OA website. The OA website will interface with all practice management software packages.

Each claim is checked for errors such as invalid dates or codes. Once you submit a claim you will receive e-mails letting you know the status of the submission, and if it has been accepted or rejected by the plan. You may immediately fix many claim errors right at the website. You can also view a history of your claims submissions.

The phone staff will walk you through the set-up process and your first claim submissions step-by-step. There are no fees for their customer service or tech support, which is available 24/7. I have found them to be very friendly and patient.

The only exceptions to their "no-fee" policy: if you are billing a plan that is not on their list of over 2000 payers, you may choose to have them mail bills for you for just 35 cents per claim (less than the cost of a stamp). Also, there is a $19.95 monthly fee if more than 50% of your claims are Medicare or Medicaid/MediCal.

Why is it free? Like all claims "clearinghouses," OA is reimbursed by the insurance plans (electronic submissions save the plans money). However, unlike most other clearinghouses, Office Ally elects not to charge the provider.

Can you tell I am a big OA fan? I urge you to check them out at www.officeally.com or contact them at (866) 575-4120 or info@officeally.com.

For complete advice about how to "navigate the insurance maze" — including how to sell yourself to EAPs and insurance companies to fill those empty therapy slots — order Barbara's book or schedule a personal consultation with Barbara.

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Electronic Billing — With or Without a Computer

From Navigating the Insurance Maze: The Therapist's Complete Guide to Working with Insurance — And Whether You Should by Barbara Griswold, LMFT
(February 15, 2009)

Insurance, computers, and change — three things many therapists avoid like the plague. A 2005 Psychotherapy Finances survey showed that only 23 percent of solo practitioners filed electronic claims. Yet it is likely that paper claims will soon become obsolete, and plans will only accept electronic claims.

So, what is electronic billing? Electronic billing is submitting claims to the insurance plan via the Internet. The biggest payoff with electronic billing is that claims are instantaneously received by the insurance company, which greatly speeds payment — sometimes cutting your reimbursement wait in half. And errors are usually caught quickly, significantly reducing claim rejection due to tiny issues such as a missing CPT code or an invalid diagnosis code.

Here are the three most common types of electronic billing:

  1. Submit directly at the plan's website. No special software is required. Claims are filed immediately with the plan, without going through an intermediary. It's free and easy, even for the computer novice. A good option for therapists who have few claims and who work with a small number of plans.
     
  2. Submit through a claims clearinghouse. This is a popular option for therapists who have (or are willing to use) billing software. The claims are transmitted from your software to a clearinghouse with whom you have contracted. The clearinghouse serves as a kind of intermediary, instantaneously converting the claims to a HIPAA-compliant secure format, then sending them to the appropriate insurance company. A good option if you work with many insurance clients or multiple insurance plans. Be sure to contact the clearinghouse to make sure the plans you bill are on their payer list, and that they can receive claims from your billing program.
     
    Sound expensive? Believe it or not, there is at least one online clearinghouse, Office Ally (www.OfficeAlly.com) which will submit your claims for FREE. And there are low cost billing software programs (Office Ally even has FREE online practice management software you can use).
     
  3. Submit through a billing service. Don't want to deal with computers or billing? Hire a billing service. After you send initial client data to the billing service, you might send a weekly list of clients seen with session dates and procedure codes), and the service will format and transmit the claims to the web site of the appropriate insurance company. The billing service may even follow-up on unpaid claims, track authorizations, and verify insurance coverage for you. Financial arrangements vary: They may offer flat-fee pricing, per-claim fees, or a percentage of your reimbursements.
     
    Karen Rose, MFT, loves her billing service. "They do absolutely all paperwork for my practice, including billing, tracking claims, dealing with unpaid claims, credentialing and re-credentialing. In fact, I now print on the back of my business cards, 'for billing questions, contact…' with their phone number. My clients contact them directly regarding billing and insurance issues, and I can just do therapy."

Sounds nice, huh?

This article is adapted from my practical, quick-read manual of what EVERY therapist should know about insurance (click here to order).

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The New PTSD: Pissed at Those Stupid Deductibles

By Barbara Griswold, LMFT
(June 16, 2008)

Deductibles may be the most confusing, annoying, and disruptive part of working with any client who seeks reimbursement from their insurance. So even if you have never signed a contract with an insurance plan, this is stuff EVERY therapist should know.

What's a deductible? This is the amount that a client with insurance has to pay out-of-pocket before the plan pays a dime.

Do all plans have deductibles? Thankfully, no. This is more common if a client sees an out-of-network therapist (one who has NOT signed a contract with the health plan), but many plans have a deductible for all providers.

What's changed? In the olden days, deductibles were usually $100, maybe $250 at the most. But lately I have seen clients with $1000, $3000, even an $8000 deductible. No kidding. This coverage is great if you get hit by a bus, but not so great if you have a garden-variety mental or physical illness.

Why the increase? Health plans are not making the huge profits they used to enjoy, so have developed this way to shift the high cost of health care to their members. Coupled with ever-increasing premiums and larger copayments (often $30 or $40), therapy is becoming much more expensive for clients with insurance.

Why is this so important? Let's look at an example. You are a contracted provider with the client's health plan, which pays you $60 per session. Your client pays her $20 copayment at each session. At the end of the month, you submit a claim. When the Explanation of Benefits (EOB) arrives six weeks later, you get no payment because the client has a deductible of $600. Now ten weeks into treatment, you turn to your client to pay the $400 balance (remember she paid $20 at each session). At the very least your client may be ticked off. Even worse, your client may not be able to pay you, and may drop out of treatment. Worse yet, your client may have already ended treatment in the ninth session, making it harder to collect.

What if my client pays in full when she comes? Let's say she submits the bill to her insurance plan, and finds out when the claim is processed that the plan won't reimburse her because of the deductible. She may have counted on this reimbursement when choosing to see you. So she might be annoyed that you didn't give her this important information ahead of time. And if she isn't going to be reimbursed, she may be unable to continue treatment.

There's more. Let's return to the example above. As a preferred provider, the plan will only count your $60 contracted rate toward the deductible — you cannot charge more for any session you have with this client. If your client has a $600 deductible, the plan will not start paying until the 11th session.

Let's say you are NOT a contracted provider with the plan. In our example, you charge $125, but the plan caps its reimbursement at $80 per session for an out-of-network provider. Due to your client's $600 deductible and this $80 cap, she will not be reimbursed at all until the seventh session. Starting at the eighth session, her plan won't reimburse her for $20 of each session (this is her copayment, the client's portion of the bill) AND won't reimburse the $45 difference between the $125 she paid you and the plan's $80 cap. Final tally? Of the $125 she paid you for the session, she will not be reimbursed for $65 of her payment, or more than half.

There's even more. One of my clients has an employer who has chosen a less expensive Blue Cross plan, which pays a maximum of $25 for each session. This means that only $25 is applied to the $600 deductible for each session. This means if your contract rate with Blue Cross is $67, your client will have to pay $67 out-of-pocket until the deductible is used up in the 25th session. After that, her copayment will be $42.

Just to make this more annoying, some plans have one deductible that applies to any of the client's medical or mental health visits. But some have a separate mental health deductible, which may be split between you and any psychiatrist or other therapist (e.g. a couples therapist) that the client is seeing. This means the client's visits to medical doctors may not reduce their mental health deductible.

One final complication: The deductible usually starts again at the end of the calendar year. This means when your client finally uses up her deductible, the whole out-of-pocket dance will start again in January. Have I completely confused you yet?

Have I completely confused you yet?

My advice? Remember that even if you've never signed a contract with an insurance plan, this deductible stuff applies to your clients, too. This is one reason I STRONGLY advise ALL therapists to check coverage after the first session. In fact, I often get insurance information on the first phone call, telling my client that I want to be sure there are no surprises for them down the line. After this call, I'll be able to inform a client if there will be no reimbursement for the first session(s). Then your client can decide if she can afford treatment — and you won't be stuck trying to collect for an unpaid session.

You will need to ask the plan numerous questions, including whether the client has a deductible, how much it is, whether the deductible varies by diagnosis, how much of the year's deductible has been used, and if this deductible is for mental health only. In my book, Navigating the Insurance Maze, I've included a helpful worksheet outlining 6 questions you should ask clients about their plan, and 12 essential questions to ask the plan when checking coverage. I also explain why you should never trust what the client or her health card says about her coverage.

To learn more about handling insurance issues like this that EVERY therapist should know, check out my book Navigating the Insurance Maze: A Therapist's Complete Guide to Working with Insurance – And Whether You Should — just click here — or to order the book, click here.

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Barbara Griswold, LMFT, is the author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance — And Whether You Should. E-mail barbgris@aol.com, visit her Website at www.navigatingtheinsurancemaze.com, or call 408.985.0846 to purchase the book or the new forms, to find out about upcoming workshops, or to get answers to your insurance questions.

Copyright 2008-2009, Barbara Griswold, LMFT. No part may be reproduced without written permission of the author.

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