Taking Insurance

  • Thread starter Thread starter deleted1129370
  • Start date Start date
Therapulse.ai - The AI Scribe for Mental Health
This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
D

deleted1129370

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?
Members don't see this ad.
 
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.
 
Last edited:
Members don't see this ad :)
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.
 
Sanman said:
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.
Click to expand...

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

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

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.
 
texanpsychdoc said:
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.
Click to expand...
That’s a solid approach.
 
PsyDr said:
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.
Click to expand...
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.
 
PsyDWannabe said:
That’s a solid approach.
Click to expand...
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?
 
texanpsychdoc said:
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?
Click to expand...
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.
 
PsySeeker said:
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?
Click to expand...

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.
 
PsySeeker said:
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?
Click to expand...
In this other plans then psychiatrists may complain that there's no distinction in pay between them and psychologists. Circle of life.
 
Members don't see this ad :)
Heist said:
In this other plans then psychiatrists may complain that there's no distinction in pay between them and psychologists. Circle of life.
Click to expand...

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

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.
 
texanpsychdoc said:
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.
Click to expand...
99242 is a 30 minute code? 99241 is 15
 
Heist said:
99242 is a 30 minute code? 99241 is 15
Click to expand...

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...
 
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.
 
Heist said:
In this other plans then psychiatrists may complain that there's no distinction in pay between them and psychologists. Circle of life.
Click to expand...
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.
 
texanpsychdoc said:
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.
Click to expand...
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.
 
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 said:
That seems absurd! Is that standard practice?
Click to expand...

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.
 
Harry3990 said:
That seems absurd! Is that standard practice?
Click to expand...
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.
 
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 said:
I do my own clinical billing. Takes about an hour or two every quarter.
Click to expand...

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.
 
texanpsychdoc said:
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.
Click to expand...

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.
 
smalltownpsych said:
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. 😁
Click to expand...
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.
 
WisNeuro said:
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.
Click to expand...
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.
 
AcronymAllergy said:
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.
Click to expand...

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.
 
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.
texanpsychdoc said:
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.?
Click to expand...

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.
 
calimich said:
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.
Click to expand...

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

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.
 
texanpsychdoc said:
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.
Click to expand...

Ah, that was my mistake, I thought they also took a % cut along with the .25 after those included 35.
 
WisNeuro said:
Ah, that was my mistake, I thought they also took a % cut along with the .25 after those included 35.
Click to expand...
Therapy Notes is .14 per claim, but a claim can have as many sessions for a person as you want.
 
You must log in or register to reply here.

Similar threads

Sanman
Insurance woes
Replies
19
Views
2K
AcronymAllergy
AcronymAllergy
P
Liability Insurance
Replies
6
Views
1K
msc545
M
P
Taking good notes why interviewing/evaluating patients
Replies
5
Views
765
AcronymAllergy
AcronymAllergy
B
Taking the EPPP before postdoc in NY: Is it possible?
Replies
2
Views
627
BrainStormer
B
D
Getting on with insurance panels
Replies
8
Views
1K
WisNeuro
WisNeuro
Top