Insurance reimbursement CAP

[MrFlyGuy]

I have heard that insurance will often reimburse CAP higher due to need for services. For this to happen do you need to have board certification or just complete fellowship/see a majority of CAP patients?

MrFlyGuy

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[comp1]

Billing codes are billing codes, right? You might be able to add some complexity add ons. Are you thinking about salaries?

 

[MrFlyGuy]

No, insurance companies (private ones) offer higher reimbursement rates for CAP. At least that is what I heard.

 

[calvnandhobbs68]

No, insurance companies (private ones) offer higher reimbursement rates for CAP. At least that is what I heard.

You might be talking about something like this?

https://lukegale.com/wp-content/uploads/2024/07/CPIP-Overview-2024.pdf

But this kind of stuff isn't widespread. What I get paid by insurance is the same as the adult psychiatrists.

 

[MrFlyGuy]

Yes, something like this. You can look up in prior posts on this forum that people are reporting that they are being reimbursed a certain percentage higher than their adult counterparts. I suppose it could depend on the area and the demand/need for CAP.

 

[clozareal]

You have higher negotiating power if you say you are filling a niche. I had to send over my board certification to insurances for them to offer me higher rates (which I ended up not taking anyways).

 

[MrFlyGuy]

You have higher negotiating power if you say you are filling a niche. I had to send over my board certification to insurances for them to offer me higher rates (which I ended up not taking anyways).

Can I ask what rates you were getting post negotiation for 99214 + 90833 and why you ended up rejecting taking on those insurance panels?

 

[Atreides]

In MA, BCBS will reimburse 50% higher for the same CPT codes if you're board certified in CAP.

 

[clozareal]

Can I ask what rates you were getting post negotiation for 99214 + 90833 and why you ended up rejecting taking on those insurance panels?

99214 = $195, up from $106.40 before negotiation
90833 = $102, up from $40 before negotiation

I filled up fast enough with private pay patients during the contract negotiation process that I didn't want to go through the headache of taking insurance.

 

[Merovinge]

99214 = $195, up from $106.40 before negotiation
90833 = $102, up from $40 before negotiation

I filled up fast enough with private pay patients during the contract negotiation process that I didn't want to go through the headache of taking insurance.

It's still certainly a thing that insurance will pay almost $600/hour seeing 2 patients/hour for f/u. I know there is significant overhead and headache just to deal with them but still not a bad way to go.

 

[calvnandhobbs68]

In MA, BCBS will reimburse 50% higher for the same CPT codes if you're board certified in CAP.

Yes that's the document I linked to above.

99214 = $195, up from $106.40 before negotiation
90833 = $102, up from $40 before negotiation

I filled up fast enough with private pay patients during the contract negotiation process that I didn't want to go through the headache of taking insurance.

Those went from incredibly bad rates to incredibly good rates. I'm on like 6 different insurance panels and they all land between those numbers for both of those codes.

I put that I was CAP when applying for most insurances because they expedite your credentialing if you're a "critical access" specialty but haven't heard of anyone getting higher rates just because they're CAP here. Insurance markets are super regional so that's not to say it doesn't happen in other regions.

 

[MrFlyGuy]

99214 = $195, up from $106.40 before negotiation
90833 = $102, up from $40 before negotiation

I filled up fast enough with private pay patients during the contract negotiation process that I didn't want to go through the headache of taking insurance.

I'm having no luck getting private patients. Do you have any advice? Ideally I would like to just go private but insurance certainly makes it easier to fill up a patient panel.

 

[clozareal]

I'm having no luck getting private patients. Do you have any advice? Ideally I would like to just go private but insurance certainly makes it easier to fill up a patient panel.

What have you tried and what's the issue?

 

[Stagg737]

99214 = $195, up from $106.40 before negotiation
90833 = $102, up from $40 before negotiation

I filled up fast enough with private pay patients during the contract negotiation process that I didn't want to go through the headache of taking insurance.

If you don't mind, what do you generally charge and how many hours per day/week are you working? I assume you're not billing CPT cods if you're doing cash only, but how often do you think you would use that 90833 add on? Feel free to PM if you prefer.

 

[rjs2131]

If you don't mind, what do you generally charge and how many hours per day/week are you working? I assume you're not billing CPT cods if you're doing cash only, but how often do you think you would use that 90833 add on? Feel free to PM if you prefer.

Not sure if helpful or not, but I'm CAP in PP and almost exclusively take insurance. We get in the ballpark of $240 for a 99214+90833, and this is how I bill 99% of my follow-ups (30 min). I work around 27 clinical hours/week (started around 30 but have cut back to have a half-day on Fridays). Our cash rates are pretty similar (~$220 per 20-25 min follow-up).