New To Private Practice & Insurance Billing?

Clinicians venturing out into private practice often find the idea of billing insurance to be very intimidating, as it is often assumed to be a very complicated process. It is my intention to take some of the mystery out of the process so that you will find increasing comfort with and understanding of all aspects of insurance billing.

Follow these six steps to achieve success in the claims submission process!

In this Article:

Step 1: Prepare for Credentialing

Credentialing is a process that the insurance companies use to ensure that you are qualified to serve on their panel. Insurance companies often list their credentialed providers on their websites, and their customers often use the insurance company website in order to find providers who accept their insurance in the local area. 

If you are not credentialed as a provider with the insurance company, you may have the option to bill the company as an out-of-network provider, but there is no guarantee of your claim being accepted. It actually depends on the patient's policy if they pay for out-of-network provider. Most government insurance companies such as Medicare, Medicaid, and Tricare will not pay any out-of network providers.   
  • Consider asking a therapist seasoned in private practice to mentor you as you go through this process. Their wisdom about the local insurance companies can be extremely valuable. There are also consultants who will provide sound advice and recommendations for you in return for a consulting or coaching fee.  
  • Consider getting a separate tax ID number/setting yourself up as a company. I.E. John Doe, Ph.D. LLC. Use this number to credential with insurance and obtain malpractice insurance.
  • Obtain malpractice insurance
  • Get an NPI number
  • Be licensed in the state where you provide services
  • Know your taxonomy code if you are going to be a Medicaid or Medicare provider.
  • Create a profile with www.CAQH.org Many insurance companies use this company as a credentialing database. Keep it updated at least every six months, and be sure and update it as soon as your license or malpractice insurance is renewed for the year.
  • Have a practice location in place already? Credentialing includes your practice address.

Step 2: Credentialing With Insurance

If you do some searching, there may be some companies/individuals out there who will do all of your credentialing legwork for a fee. Depending on the amount of time you have to spend on credentialing, it may make economic sense to have someone else do the paperwork while you make money treating your clients.   
If you were previously working for a larger clinic, you might think that you are already a paneled provider with an insurance company, but in many cases, you were likely working under your old employer's contract with the insurance company. DO NOT ASSUME! If you do not have a contract from the insurance company with your name on it, you likely aren't credentialed, and claims will be denied. 
Be aware that the credentialing process may take months, depending on the insurance company, and that many insurance companies may not be accepting new providers on their panels. Even others may require at least three years of licensure before allowing you to be on their panel. Also, insurance companies may not be accepting new providers onto panels in your area. If that is the case, continue to apply every six months to a year in case they open up availability. 
  • Contact the insurance companies' provider relations department and ask for a credentialing application. Know if you are credentialing as a group or as an individual provider.
  • Make sure that all of your practice locations are credentialed.
  • Review the contract before you sign it. Be aware of their documentation requirements, claims submission requirements (many are requiring electronic claims submission), appeals process for denied claims, fee schedule, reimbursable CPT codes for your license/specialty, diagnosis codes that you will be reimbursed for, modifier codes, if any, and how long you have from a date of service to submit a claim to the insurance company.
  • Keep a copy of the contract on file, and add any contract addendums to that file.
  • Access: After you are credentialed, you will be allowed access to the provider portion of the insurance website. Create a username and log-in for the insurance companies' websites, and learn your way around. Their websites are handy to view client policy info, look at claims already paid, claims in cue, and the process for appeals.
  • Record the insurance company's phone numbers for provider relations, claims department, and service pre-authorizations. Create a master file with all of this information available at your fingertips, along with your usernames and passwords. Keep it in a safe place, as your login will access past claims payments which will include your proprietary numbers and diagnosis that no one else need have access to. 

Step 3: Have a Practice Management System in Place

  • Consider TherapyAppointment to manage your scheduling, records, insurance claim filing, patient invoicing, income reporting, patient reminders, practice statistics, patient demographics, and patient biographies. Create a practically paperless office.
  • To sign up with us for a free 30 day trial with us click here!
  • Request EPS (electronic payment service) and ERA (electronic remittance advice) through your insurance company.If you are already set up with TherapyAppointment, you can have your EOBs set up to automatically download into our system and automatically post to the patient's account--a big timesaver for any practice! 

Step 4: Know Your Client's Insurance Plan 

Some Insurance companies may delegate the management of some of their plans or some services within plans (such as behavioral health) to other companies. Failure to realize this could result in a claim being submitted to the wrong company or you not being credentialed by the company which handles mental health benefits, which will result in a claim denial or delayed payment.
Don't assume your patient is an expert on their own insurance policy. In fact, assume the opposite. Your patient is counting on you to be the expert! 
  • Ask the patient to provide you their insurance company name, ID number, and group number over the phone or by some other means so that you can verify their insurance. If you use TherapyAppointment, you have the opportunity for the patient to enter this information into your data automatically through our online portal, reducing time on the phone and simplifying insurance billing.
  • Call the insurance company or log into the insurance website to view if the patient has an active insurance plan and to check is mental health services you plan on providing are covered by their plan.
  • Review the copays/coinsurance that is the patient's responsibility to pay at each session. Know if there is a deductible yet to be met by the patient for services. If the patient has a deductible in force for your type of services, the patient will need to pay you the contracted rate for your services until their deductible has been met. TherapyAppointment reminds you what the client's copay amount is every time you provide the client services.
  • Verify that the patient's insurance plan covers the treatment you are providing (i.e. marital therapy is often not covered by insurance plans, but may be covered by Employee Assistance Programs). TherapyAppointment provides you a special memo section for each patient in order to keep all the notes about insurance and referrals that you need.
  • Obtain a pre-authorization or pre-certification for procedures that require this prior to services being rendered. Psychological testing almost always requires a preauthorization from the insurance company. Some insurance companies may allow you to ask for pre-authorizations through their website; others will require you to call them to obtain the authorization. Record the authorization start and end dates, the CPT codes covered by the authorization, and the number of sessions authorized. It is also helpful to make a note of who you talked with at the company along with the phone number in case you need to call again or have any denied claims. TherapyAppointment offers you the opportunity to keep track of all of this data. We inform you when your pre-certified session are running low or timing out. We automatically put the authorization number on every claims for insurance billing.
  • Ask the insurance company if the patient's insurance require a physician's referral. It pays to find out! TherapyAppointment provides the means to submit claims with the referring physician's NPI number so that you get reimbursed.
  • Determine if this patient has an out-of-state insurance plan. Even if the company is one which you are credentialed with, you might find that your reimbursement rate is different; you might need prior authorization; or perhaps, you might be required to sign a single-case agreement with the out-of-state company. It is fairly common for out-of-state plans to take longer than usual to pay when they do accept your claim.
  • Confirm where claims are to be sent. Either find out the electronic ID number and the claims mailing address so that you can ensure the claim is submitted correctly.

Step 5: The Patient's First Visit

  • Make a copy of their insurance card and driver's license number. Keep it on file.
  • Ask them to sign a statement which gives you their 'signature of file' so that you may file insurance claims. TherapyAppointment allows you to upload a scanned in card and documents into the patient's file and keep it on record in order for you to be a practically paperless office!
  • Document the visit according to the requirements of the insurance company, HIPAA, and your state licensing board. Always follow the rules of the entity which has the most stringent requirements. TherapyAppointment allows you to document and bill insurance in one simple step with several documentation styles available for you to meet your particular guidelines.
  • File the insurance claim the same day if possible in order to find out more swiftly if benefits differ from those quoted to you by the insurance company website. You have better opportunities to collect from patients who are current and actively seeing you for treatment. Sending electronic claims to insurance companies daily through TherapyAppointment ensures your claim is processed as quickly as possible by the insurance company.

Step 6: At Every Visit

  • Confirm the patient's insurance company and plan has not changed. If a client changes jobs, be aware that they may no longer have active insurance. The beginning of a new calendar year often means different insurance numbers, different deductibles, and different copays than the previous year. Plan on January to be busy with this verification process!
  • Ensure the client pays their copays or the entire insurance contracted session fee if they still have a deductible.
  • Document the procedure code (CPT) code to be billed for insurance. 
  • Document the session according to your insurance guidelines, licensure guidelines, and HIPAA guidelines, using the most restrictive rules as your minimum requirements.
  • Review the client's past payments and any amount due/denied by insurance. TherapyAppointment automatically informs you when a claim is denied or not paid in a timely manner when you log in to view the client's file.