Let's not forget that most insurance policies (stateside) currently pay mental health care as a limited benefit (e.g., 50% ucr w/ a max # of visits or overall amount per year) compared to "other" health care providers who are eligible for 80-90% ucr without such stipulations. Makes a large difference in your income, particularly when your patients refuse to pay the other 50% because they do not understand why their insurance is only paying half of their bill to begin with.
Would these estimates be the same for an LCSW?
If not, whats the difference?
I'm curious about this as well.
It's been my experience (both working for managed care and as a provider on several panels) that there are typically three fee schedules: 1. MD/DO get reimbursed more than 2. PhD/PsyD who get reimbursed more than 3. LCSW/LPC/LMFT. Sometimes there's a fourth with psych nurse practitioners.
When you choose to participate on a panel, you agree to the appropriate fee schedule for your license- considered the usual and customary (UCR) charge. As an in-network provider, you are not permitted per your contract to bill for the difference between the UCR and your billed fee.
Example: Let's say I charge $100 per 50 minute hour and am on panel for HMO A. My contract with HMO A is that I will accept $60/hour. Client A comes in to see me, and pays his copay. I bill HMO A and will receive $60 minus the copay received. So if copay is 20, I get 40 from HMO A. Copay is 30? I get 30- etc etc etc. I eat the $40 difference between HMO A's UCR and my $100 fee. If I attempt to recover that difference, I am in violation of my contract and can be removed from the panel, face legal issues, etc.
When you are not on a panel and see a member who wants to use their out of network benefits, you can recoup the difference because you are not under contract.
Example: I still charge $100, and am not on panel with HMO B. Someone with HMO B comes in(actually, I guess that wouldn't be "hmo" would it? probably ppo or pos, but I digress..) and wants me to bill their insurance. Out of network benefits are almost always at a higher cost to the member, and often there's a deductible to be met first. So let's say deductible of $500.. HMO B gets a bill for the first 5 sessions and no reimbursement is given to anyone. At session 6, the benefit will kick in. Let's say it's "70% of UCR after the deductible is met", and that HMO B has the same $60 UCR as HMO A does. Starting with session 6, HMO B will pay out 70% ($42) of the $60 UCR, leaving a $58 difference between what they've paid and my billed charge. I may bill the patient for the remaining $58. For out of network, I took my cue from a psychiatrist I work with- I collect the full fee at the time of service, then request that the reimbursement be sent directly to the patient. If it comes back to me, then their account is credited.
Of note:
UCR is set separately by each insurance company, although many do use CMS guidelines. I have a different reimbursement level for each company I work with, and am in the midst of re-credentialing with several of them right now (3 year intervals). I'm closing my practice in a couple of months anyway, but have had the luxury of deciding which companies to recredential with based on a) how much paperwork they require of me and b) reimbursement rate. I'm happy to say two companies' recredentialing packets have gone directly into the vertical file.
