Taking Insurance

[texanpsychdoc]

So I took the plunge and applied to several insurance panels: Aetna, BCBSTX, Cigna, United Healthcare, Humana, and Beacon.

Interestingly enough, I was fully approved and became paneled with United in like 2 weeks, and I am almost done being paneled with Cigna. My biggest hang up has been with BCBSTX who rejected my application because my W-9 was incorrect, so I re-submitted the application. It is challenging getting to know my status with them honestly. I haven't heard a peep from Aetna, Beacon, or Humana.

In the end, I am a bit nervous taking insurance as this is completely uncharted territory for me. I suppose a fear of mine would be that I take on an insurance patient, and their benefits run out during the course of treatment, or, they no show or cancel. My current no show fee applies to my private pay folks, but could I apply that to my insurance folks?

For those who take insurance, any words of wisdom or insight?

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[Doctor Eliza]

In my experience, it isn't so much that the benefits run out. It is usually the opposite: they have a big deductible up front that they don't expect.

No show fees can be charged to the patient directly. Insurance won't pay them, but the client certainly can be held responsible.

 

[PsyDr]

You have to read the providers' handbook for each insurance. That will tell you the rules. There are likely differences between the types of policies for each insurance company (e.g., Acme Bronze Plus might have different rules than ACME Silver). Some rules will require preauthorization, or limit treatment, or require specific documentation. No one can tell you what those rules are, for each variety of policy for each insurance company. However, it is unlikely that the contracts allow you to bill for no shows. There is some work around, with an agreement after you have signed consent. However, this verges on something called "balance billing" which can be illegal.

If their benefits run out, they pay out of pocket at the contracted U&C rate, not your cash rate. It is likely a breach of contract to do otherwise, and potentially fraud.

There is a lot here, you REALLY need to read the handbooks. And take some CEs on billing.

 

[Sanman]

Just curiosity, why are you applying for so many panels? For a solo practitioner, I could see getting by with 1-2 contracts depending on the type of work.

 

[WisNeuro]

Just curiosity, why are you applying for so many panels? For a solo practitioner, I could see getting by with 1-2 contracts depending on the type of work.

I am paneled with Medicare +2 others and am currently scheduling in June. If you take insurance, filling clinical slots is easy mode.

 

[texanpsychdoc]

Just curiosity, why are you applying for so many panels? For a solo practitioner, I could see getting by with 1-2 contracts depending on the type of work.

Mostly to cast a wide net to see who will pay the most. Just because I applied to them doesn't mean I will sign contracts with them. I am waiting for them to show me their rates, which is what Cigna and United did. Once I saw their rates, I signed their contracts, they credentialed me, and the rest is history. I was really looking to take between 1-3 carriers, preferably United, Cigna, and BCBS.

 

[texanpsychdoc]

I am paneled with Medicare +2 others and am currently scheduling in June. If you take insurance, filling clinical slots is easy mode.

I have heard the same from several others - once you get paneled, you can fill your practice up soon. I also applied and subsequently received my group NPI so I can re-apply with these companies to be paneled as a group practice, then I can start hiring some folks in the future to scale and grow the practice.

I am proud of the fact I did all of this on my own - I didn't outsource this to a 3rd party credentialing company. But it's been stressful.

 

[PsyDWannabe]

Mostly to cast a wide net to see who will pay the most. Just because I applied to them doesn't mean I will sign contracts with them. I am waiting for them to show me their rates, which is what Cigna and United did. Once I saw their rates, I signed their contracts, they credentialed me, and the rest is history. I was really looking to take between 1-3 carriers, preferably United, Cigna, and BCBS.

That’s a solid approach.

 

[PsySeeker]

You have to read the providers' handbook for each insurance. That will tell you the rules. There are likely differences between the types of policies for each insurance company (e.g., Acme Bronze Plus might have different rules than ACME Silver). Some rules will require preauthorization, or limit treatment, or require specific documentation. No one can tell you what those rules are, for each variety of policy for each insurance company. However, it is unlikely that the contracts allow you to bill for no shows. There is some work around, with an agreement after you have signed consent. However, this verges on something called "balance billing" which can be illegal.

If their benefits run out, they pay out of pocket at the contracted U&C rate, not your cash rate. It is likely a breach of contract to do otherwise, and potentially fraud.

There is a lot here, you REALLY need to read the handbooks. And take some CEs on billing.

I mean, it depends on what we mean by “if their benefits run out.” If their benefits are actually terminated and they continue with either OON or cash, you revert to charging them your cash rate.

 

[PsySeeker]

That’s a solid approach.

CIGNA’s rates are an absolute horror show here. They are the only major national or regional payer that makes no distinction between psychologists and master’s. The majority of other carriers have recently gone the other direction, raising psychologists rates to parity with psychiatrists.

Cigna’s rate for 90837 was recently roughly little more than half of the 5 or so other commercial payers here and same for the regional Medicare rate. Hell, they are maybe about 70% or so of regional Medicaid rates. It’s just astoundingly bad, so I refused to sign. They asked me to give them what rates I thought would be fair, as if they don’t know Medicare’s or the other commercial payers’ rates. They said they would not negotiate, but if I signed up I could request a rate change after a year…

I don’t know what they are aiming for or why it’s so dramatically bad, maybe a network with no in-network psychologists?

 

[medium rare]

So I took the plunge and applied to several insurance panels: Aetna, BCBSTX, Cigna, United Healthcare, Humana, and Beacon.

Interestingly enough, I was fully approved and became paneled with United in like 2 weeks, and I am almost done being paneled with Cigna. My biggest hang up has been with BCBSTX who rejected my application because my W-9 was incorrect, so I re-submitted the application. It is challenging getting to know my status with them honestly. I haven't heard a peep from Aetna, Beacon, or Humana.

In the end, I am a bit nervous taking insurance as this is completely uncharted territory for me. I suppose a fear of mine would be that I take on an insurance patient, and their benefits run out during the course of treatment, or, they no show or cancel. My current no show fee applies to my private pay folks, but could I apply that to my insurance folks?

For those who take insurance, any words of wisdom or insight?

One thing I’ll add is that if you have any desire to not take insurance in the future or only take limited insurance, be selective of the carriers you initially contract with. I’ve known several psychologists over the years who signed up with multiple insurances just to get started and then had difficulty reducing/eliminating their insurance participation later.

It can be difficult/take a good amount of time to resign from a panel not to mention having the patient decide whether to stay with you for cash or find another provider. Also, if you join most panels in your area, you effectively eliminate the referrals who may be willing to see you for self-pay.

 

[texanpsychdoc]

CIGNA’s rates are an absolute horror show here. They are the only major national or regional payer that makes no distinction between psychologists and master’s. The majority of other carriers have recently gone the other direction, raising psychologists rates to parity with psychiatrists.

Cigna’s rate for 90837 was recently roughly little more than half of the 5 or so other commercial payers here and same for the regional Medicare rate. Hell, they are maybe about 70% or so of regional Medicaid rates. It’s just astoundingly bad, so I refused to sign. They asked me to give them what rates I thought would be fair, as if they don’t know Medicare’s or the other commercial payers’ rates. They said they would not negotiate, but if I signed up I could request a rate change after a year…

I don’t know what they are aiming for or why it’s so dramatically bad, maybe a network with no in-network psychologists?

Yeah when I signed with Cigna I saw their rates for 90791, 90837, 90834 and was like "my goodness." So for me, I think I'd really try to focus on only taking Cigna folks for testing as their rates are a bit better than some others.

 

[PikminOC]

CIGNA’s rates are an absolute horror show here. They are the only major national or regional payer that makes no distinction between psychologists and master’s. The majority of other carriers have recently gone the other direction, raising psychologists rates to parity with psychiatrists.

Cigna’s rate for 90837 was recently roughly little more than half of the 5 or so other commercial payers here and same for the regional Medicare rate. Hell, they are maybe about 70% or so of regional Medicaid rates. It’s just astoundingly bad, so I refused to sign. They asked me to give them what rates I thought would be fair, as if they don’t know Medicare’s or the other commercial payers’ rates. They said they would not negotiate, but if I signed up I could request a rate change after a year…

I don’t know what they are aiming for or why it’s so dramatically bad, maybe a network with no in-network psychologists?

In this other plans then psychiatrists may complain that there's no distinction in pay between them and psychologists. Circle of life.

 

[Sanman]

In this other plans then psychiatrists may complain that there's no distinction in pay between them and psychologists. Circle of life.

Sure there is, you guys bill the E&M code in addition to the psychotherapy code. That number can easily be adjusted if you are paid the same as NP/PAs. Not that most psychiatrists take insurance in PP anyway. I just don't see the point of the in fighting.

 

[texanpsychdoc]

In this other plans then psychiatrists may complain that there's no distinction in pay between them and psychologists. Circle of life.

You have the 99242, 99243, and 99244 that pay very nicely....like, you are easily making $300-400 an hour if you use 99242 x 4 in an hour. Psychologists can't bill those codes for now....perhaps RxP psychologists can. Not sure.

 

[PikminOC]

You have the 99242, 99243, and 99244 that pay very nicely....like, you are easily making $300-400 an hour if you use 99242 x 4 in an hour. Psychologists can't bill those codes for now....perhaps RxP psychologists can. Not sure.

99242 is a 30 minute code? 99241 is 15

 

[texanpsychdoc]

99242 is a 30 minute code? 99241 is 15

Perhaps my contract I don't see that code...but I see 99242 which is " OFFICE/OP CONSLTJ NEW/EST PT SF MDM 20 MINUTES."

Wasn't sure if that was a 20min. minimum or if there was a range like 16-20 minutes...

 

[WisNeuro]

20 minute minimum code, and I thought they deleted 99241 for 2023?

 

[texanpsychdoc]

Even with a 99242 you can still get nearly $300 an hour if you bill that 3 x patients in 60 minute hour. Psychiatrists still have a good leg up on us even with reimbursements. I could be wrong, but my understanding is the calculus involved in determining contracted rates deals with the 1. license type, 2., location, 3. other playerss in the market (aka: saturation), 4. types of services you offer vs. other paneled providers. I believe I saw somewhere there is a percent difference on license type, so even if psychologists bill for a 90837, our reimbursement rate won't be the same for a psychiatrist. I think this falls in line with the whole "the biggest difference between psychologists and masters level providers is $20." I am unsure what the difference would be between psychologists vs. psychiatrists for reimbursements of the same CPT code.

 

[PsySeeker]

In this other plans then psychiatrists may complain that there's no distinction in pay between them and psychologists. Circle of life.

Well, they are actually aren’t as nearly as qualified to provide therapy as a cohort, so even maintaining parity (or even the ability to provide therapy without being required to have any formalized training in it) is a bit of a gift grounded in legacy imo.

 

[PsySeeker]

Even with a 99242 you can still get nearly $300 an hour if you bill that 3 x patients in 60 minute hour. Psychiatrists still have a good leg up on us even with reimbursements. I could be wrong, but my understanding is the calculus involved in determining contracted rates deals with the 1. license type, 2., location, 3. other playerss in the market (aka: saturation), 4. types of services you offer vs. other paneled providers. I believe I saw somewhere there is a percent difference on license type, so even if psychologists bill for a 90837, our reimbursement rate won't be the same for a psychiatrist. I think this falls in line with the whole "the biggest difference between psychologists and masters level providers is $20." I am unsure what the difference would be between psychologists vs. psychiatrists for reimbursements of the same CPT code.

Many payers are paying psychologists at parity with psychiatrists for whatever codes they can bill. That would include E&M for RxP. This is the case for the major players and regional players here, save one national one that still discounts it 10%.

I don’t know where you saw “the biggest different between psychologists and masters is $20.” If we are talking about commercial in-net reimbursements I generally see about a 25% (not dollars) spread, or roughly 35 to 38 bucks more per hour of therapy (90837), not insignificant.

 

[smalltownpsych]

BC/BS was first insurance I applied for and after they wouldn‘t disclose the rates until I signed the contract, I decided to not take them or anyone else for that matter. One year later and my practice is full and profitable with only cash patients. Be cautious about how many you sign up for and read the fine print. Keep us posted. 😁

 

[Harry3990]

BC/BS was first insurance I applied for and after they wouldn‘t disclose the rates until I signed the contract

That seems absurd! Is that standard practice?

 

[texanpsychdoc]

That seems absurd! Is that standard practice?

I received an email from my "person" with BCBS who told me I should be receiving an agreement/contract in a few days. I have yet to see it, but they have already gone through the credentialing and contracting process with me, so I am thinking they may be pulling the same with me where I may not be able to see the rates until I sign. I hope not.

 

[smalltownpsych]

That seems absurd! Is that standard practice?

Absurd, yes. Standard practice? I heard that some do this but most do not. Insurance companies make money when they limit healthcare and so they are not motivated to get lots of docs into their networks. Some people get better while waiting and some get worse and some never need expensive treatment because they lose their insurance as they get sicker or they just die.

Although they like to call themselves healthcare companies, they clearly are not. The key difference is that we, actual healthcare companies or individuals, make our money when we treat sick people and they make money when they don’t.

 

[texanpsychdoc]

On a somewhat similar note - for those who take insurance, do you use a virtual assistant or some type of billing company that will verify benefits, submit, track, dispute denied claims, etc.?

 

[WisNeuro]

I do my own clinical billing. Takes about an hour or two every quarter.

 

[texanpsychdoc]

I do my own clinical billing. Takes about an hour or two every quarter.

Most providers I have talked to said they submit their claims either same day or weekly as to not let them pile up. I would hate to wait such a long time only to find out that they don't get paid. Heck, United says I have 90 days to submit a claim from when I see the patient.

 

[WisNeuro]

Most providers I have talked to said they submit their claims either same day or weekly as to not let them pile up. I would hate to wait such a long time only to find out that they don't get paid. Heck, United says I have 90 days to submit a claim from when I see the patient.

Clinical work is such a small part of my revenue, waiting isn't much of an issue. It's more efficient for me to do it in bulk rather than once every week or two. Rarely have something not get paid. And, even then, a quick phone call usually solves the issue.

 

[Therapist4Chnge]

BC/BS was first insurance I applied for and after they wouldn‘t disclose the rates until I signed the contract, I decided to not take them or anyone else for that matter. One year later and my practice is full and profitable with only cash patients. Be cautious about how many you sign up for and read the fine print. Keep us posted. 😁

You’d think refusing to reveal rates would be illegal, no? Back when I took insurance I not only asked for rates of the most common billing codes I used, but pitted them against each other and took the top two at the time.

 

[AcronymAllergy]

Clinical work is such a small part of my revenue, waiting isn't much of an issue. It's more efficient for me to do it in bulk rather than once every week or two. Rarely have something not get paid. And, even then, a quick phone call usually solves the issue.

It's pretty interesting how much this can vary by region and payor. We have some that pay pretty quickly and easily, and others that go on for months or more without paying.

 

[WisNeuro]

It's pretty interesting how much this can vary by region and payor. We have some that pay pretty quickly and easily, and others that go on for months or more without paying.

Pretty quick for the few that I use. Though they also have a billing cycle, so you can actually plan on doing your billing right before that cycle ends and you'd get paid very promptly.

 

[smalltownpsych]

You’d think refusing to reveal rates would be illegal, no? Back when I took insurance I not only asked for rates of the most common billing codes I used, but pitted them against each other and took the top two at the time.

They have more influence over the laws that are made than we do.

 

[calimich]

I also do my own billing. For insurance I would typically collect copays day of service and submit claims every 2 weeks. I was on two large panels and a smaller niche one. The smaller one paid the best and took the longest, maybe 5 weeks from submission. The other two took about 5 business days. I did use the smaller panel's pay scale to negotiate for a higher rate from the other two. Like others who take insurance, the referrals were nonstop. I eventually resigned from one of the larger panels and then a year or so later from the other two.

On a somewhat similar note - for those who take insurance, do you use a virtual assistant or some type of billing company that will verify benefits, submit, track, dispute denied claims, etc.?

Thankfully a very high percentage of my claims went through with no problems. However, the few that were denied definitely took time to figure out what was going on. Phone calls, hold time, emails, following up. I never enjoyed spending time tracking down a few hundred dollars that I'd already earned.

I imagine you'll be flooded with clients and able to negotiate higher rates and pick which panels you want to stay with. I looked into virtual assistants/billing companies, just never went there; it might be a good thing to outsource depending on the scale.

 

[texanpsychdoc]

I also do my own billing. For insurance I would typically collect copays day of service and submit claims every 2 weeks. I was on two large panels and a smaller niche one. The smaller one paid the best and took the longest, maybe 5 weeks from submission. The other two took about 5 business days. I did use the smaller panel's pay scale to negotiate for a higher rate from the other two. Like others who take insurance, the referrals were nonstop. I eventually resigned from one of the larger panels and then a year or so later from the other two.


Thankfully a very high percentage of my claims went through with no problems. However, the few that were denied definitely took time to figure out what was going on. Phone calls, hold time, emails, following up. I never enjoyed spending time tracking down a few hundred dollars that I'd already earned.

I imagine you'll be flooded with clients and able to negotiate higher rates and pick which panels you want to stay with. I looked into virtual assistants/billing companies, just never went there; it might be a good thing to outsource depending on the scale.

This is good to know. I am waiting for the flood gates to open - my name is already appearing in United's directory for online providers. I plan on submitting my claims through SimplePractice.

 

[WisNeuro]

What's SP charging for billing these days 3ish% plus a per billing fee?

 

[texanpsychdoc]

What's SP charging for billing these days 3ish% plus a per billing fee?

I think it varies based on your plan. One plan provides you 10 claims per month for free while another plan allows for 35 claims to be submitted for free. After you exceed the plan's respective filing limits, then it charges based on tiers.

https://support.simplepractice.com/hc/en-us/articles/115005956266-SimplePractice-pricing-and-subscription-FAQs

 

[WisNeuro]

I think it varies based on your plan. One plan provides you 10 claims per month for free while another plan allows for 35 claims to be submitted for free. After you exceed the plan's respective filing limits, then it charges based on tiers.

https://support.simplepractice.com/hc/en-us/articles/115005956266-SimplePractice-pricing-and-subscription-FAQs

Hmm, still probably much cheaper to pay someone hourly to do it every month or so.

 

[texanpsychdoc]

Hmm, still probably much cheaper to pay someone hourly to do it every month or so.

If I see 20 patients a week and roughly 80 a month, then SimplePractice allows me to file 35 claims per month for free/inclusive in my monthly membership. So, if I exceed 35, they charge $.25 per claim I submit. That means I would have to pay $.25 for 45 claims since that is in excess of the 35 I get "for free," thus, that's an extra $11.25 I would spend in addition to my monthly free of $99. So, all in for my month would be $110.25. I wonder what billing company would be cheaper than $11.25 a month.

 

[WisNeuro]

If I see 20 patients a week and roughly 80 a month, then SimplePractice allows me to file 35 claims per month for free/inclusive in my monthly membership. So, if I exceed 35, they charge $.25 per claim I submit. That means I would have to pay $.25 for 45 claims since that is in excess of the 35 I get "for free," thus, that's an extra $11.25 I would spend in addition to my monthly free of $99. So, all in for my month would be $110.25. I wonder what billing company would be cheaper than $11.25 a month.

Ah, that was my mistake, I thought they also took a % cut along with the .25 after those included 35.

 

[PsySeeker]

Ah, that was my mistake, I thought they also took a % cut along with the .25 after those included 35.

Therapy Notes is .14 per claim, but a claim can have as many sessions for a person as you want.