In the previous blog post and video I did, I have discussed some of the pros and cons of getting credentialed and starting to take insurance in your private practice as a therapist. In the last post I did on this topic, I walked through the steps it takes to become credentialed with insurance panels and become an in-network provider. And if you do decide to “take insurance” and become credentialed, you now will need to know how to file insurance claims in order to get paid by insurance companies.
Much like the credentialing process, it is important to do your legwork on the front end to be ready to start filing insurance claims for your clients. This series of blog posts is going to outline for you the steps you can take to get this going and start getting paid by insurance companies for you sessions. These have been broken down into 5 steps to take to begin the process of filing insurance claims:
Setting up a system for filing clams
Completing the Claim Form
Submitting the Claim
Follow-up on Claims Not Paid
In this first post on filing insurance claims, we will cover the setting up a system to file claims and then checking for benefits.
Most insurance companies are no longer allowing paper claims, so everything is now done electronically. When filing claims there are basically three ways to do this:
Use the insurance company provider portals. Most all of the major insurance providers have provider portals where you can file claims directly with them electronically. This can be a good option to begin with as you grow your practice or when you are only having to file a few claims per week. You will need to register with the insurance carrier as an online user which might take some extra steps. Most of those systems are very secure and require several steps for registering, such as them mailing you a “secret code” or passwords. It depends on the insurance company.
Use a Clearinghouse to file your claim. There are several advantages to using a clearinghouse. Clearinghouses receive your claim information and “scrub” it for errors before forwarding to the insurance company. Also, you can check the progress of claims and get access to electronic EOB’s (Explanation of Benefits) that shows what is owed to you and what the client owes. Also the EOB shows any deductibles that might apply.
The Clearinghouse that I can recommend and the one that I use is Office Ally. Office Ally has so many tools with it that it just seems to be a practical choice for mental health providers. They also have a Practice Management system called “Practice Mate” that handles schedules and billing. And the best part about Office Ally is that it is free to use unless they have to send out a paper claim for some reason. A those paper claims cost about 50 cents each to send. So in many ways it is a great solution for filing claims. Office Ally has tons of video tutorials that will walk you through the process.
Use EHR or PMS application or software to file your claim. Electronic Health Record software or what prefer to call Practice Management System are applications/software that you would use to keep client records such as schedules, intake information and session notes. For example, I use Therapyappointment.com as my PMS. (There are tons of others out there; ex Theranest, Therapynotes, SimplePractice, etc.) Most of the time the PMS is connected to a clearinghouse on the back end and file the claims automatically when you enter a session note. PMS usually have a monthly fee associated with them.
Once you have registered or set-up one of these systems, filing a claim just requires you entering the client information, dates of the session, diagnosis, CPT code and your billing information. The good news is that with most all of these you only have to enter the client information and billing information once and the system saves it for future claims. I will give more details about how to fill out claims and what information is needed in the next sections of this post.
One thing that is always important to do is check the benefits and eligibility of the client before you file the claim. By doing this will help prevent you from getting claims rejected as you begin filing them. It is probably preferable to do this, if possible, before the client ever comes in for the first session. So you might want to create some forms to send clients before your first session or you can simply also ask them for this information on the phone when you set up the first session. The information you will need is this:
- Client’s name as listed with the insurance
- Policy holder’s name if it is different from the client
- Date of birth for the client and the policyholder
- Member ID number and group number (if there is one)
- Your tax ID number and/or NPI number
- Sometimes you will need your provider ID number with the particular insurance company
When you get this information you can access in one of several ways. Usually, going to the insurance company website will be the easiest way. Usually there is a provider portal for you to check on benefits and eligibility.
Another way is to call the insurance company. Most all of them have an automated system that will ask you the client information,etc. It will only give you the basics of their coverage.
And yet another way to get this information is through the Clearinghouse (Office Ally) or another service which is similar to a clearinghouse called Availity. This method does not work with all the insurance companies. Nonetheless, many of the larger companies do allow you check benefits through the clearinghouse and Availity.
The information you will get is this:
- First of all, this information will let you know if the client’s plan covers your services. It will also let you know if they need a pre-authorization to use your services.
- The client’s co-pay or co-insurance amount. Co-pay is just a specific dollar amount they have to pay. Co-insurance is a percentage of the total fee or contracted rate you have with that insurance company.
- The client’s deductible amount and maximums. If a client has a deductible amount and if they have not met the deductible yet for the year, they will need to pay you the full contracted rate for the session. If they have met their maximum out-of-pocket limit for their plan they will not owe you a co-pay or co-insurance.
- You will also be likely to find out if there are any limits to the number of sessions the client is allowed under their plan.
The benefits check will also likely give you information about the payer ID, which is the code you would need for that insurance company to use with your claim. This payer ID is what clearinghouses use to know which insurance company to send the claims to.
Whew! That is a lot I know. But by breaking this down into smaller pieces it is not as daunting as it seems. And once you get yourself into the habit of doing these things, it becomes easy and only takes a few minutes to do with each client.
In the next post we will look at what is needed to actually file a claim. Also check out the post on Insurance Credentialing for the steps in the credentialing process.
Other great resources:
By L. Gordon Brewer, Jr., MEd. LMFT – Gordon is the President and Founder of Kingsport Counseling Associates, PLLC. He is also a consultant and business mentor at The Practice of Therapy. Follow us on Twitter @therapistlearn. Join the Facebook Group.