Should You Become a Network Provider? Plus Resource Review: Navigating the Insurance Maze

Welcome to Bonnie’s Navigator News blog! From time to time, I’ll post information relevant to private psychotherapy practice. When I learn new stuff related to private practice, I like to share it with colleagues! I hope this proves helpful to you. I promise not to spam your inbox. Rest assured, I don’t have time for that ;-).

In this post you will find:

Insurance Reimbursement is a Big Topic in Private Practice (and hard to address briefly)

As a newbie (and as a continuing option) in private practice, one of the most important questions you will be confronted with is: Should I become a network provider on insurance panels or only accept Private Pay?

The Truth

Dealing with insurance companies can be intimidating and frustrating. Even after five years of private practice, I still get kinda irritable and nervous when things go haywire on the insurance end of things – thankfully that doesn’t happen very often.

The process of becoming a provider on insurance panels is daunting. Applying is a multi-step process. It takes attention to detail, time, and uber patience.

Learning how to submit claims and deal with payments is another learning curve. You have choices about how to handle this part. You can do it all yourself (with or without paid services) or pay for billing services so you don’t have to deal with the claim submission process.

Dealing with certain technicalities, e.g. finding the address to submit claims, authorizations, and denials can be annoying and time-consuming. Learning the basics from the start will help you be efficient and reduce denials. Again thankfully, I rarely get a denial. Some things are out of our control, for example, when an insurance company pays the claim incorrectly. Knowing what to do is easy to learn. Maintaining patience through the process might be the hardest part.

I am on a number of insurance panels. For me, the pay off has been totally worth the time and effort to get on those panels and deal with the occasional complications that have arisen. While the details are confusing, none of it is rocket science. Really. You too can learn this stuff.

I decided from the start to become a network provider on several commercial insurance panels, Medicare, and Medi-Cal (California Medicaid).  The benefits have paid off:  

  • I get referrals regularly from several insurance companies – in fact, my practice has been full for a long time. As soon as there is an opening, the space gets filled up quickly.
  • I feel good offering a service the client is/has paid for through their insurance plan
  • I feel good about serving lower-income clients who are on a Managed Care Medi-Cal (Medicaid) Plan or have Medicare/Medi-Cal.
  • I don’t have to “sell” myself in terms of payment. The only payment the client is responsible for under commercial insurance and Medicare are the Deductibles, Copays, and Coinsurance portions.
  • My clients don’t usually quit due to the cost of therapy (there have been exceptions like when they have a large copay or haven’t met their deductible and it’s still all out of pocket)
  • The unexpected benefit of receiving news, clinical guidelines, and general information from insurance company newsletters. Some offer free trainings.

“But, Bonnie,” you ask, “If I am going to be a Private Pay Only therapist, do I still have to learn insurance mumbo-jumbo? Can’t I just skip all that head-spinning stuff?” The short answers: YES, you do need to learn a few things about insurance anyway, and NO, you really shouldn’t skip it – you could commit insurance fraud, risk your license, and not even know it.

The long reply to the “Yes” answer above – 

If you decide to accept Private Pay only, at the very least you will need to have a clear understanding of:

  • how to prepare your Private Pay Agreement
  • what CPT codes are and how to use them on your Superbill/Invoice
  • how to answer questions when clients ask you about reimbursement from their insurance company
  • how to prepare a Superbill/Invoice so the client can submit for possible partial reimbursement from their insurance company
  • your status (or non-status) as a “Medicare-eligible provider” (clinical social workers and clinical psychologists with the correct licensing in their state)
    • your choices regarding Participation, Non-participation, and Opting Out of Medicare and how it affects the client and your fees. If you have the correct licensing for your state, you are already considered a “non-participating provider” by virtue of your licensing, even if you don’t “Opt-Out.”
    • I highly recommend you read the following if you ever plan to accept a client with Medicare: Medicare Part B 101 Manual: Assignment of Benefits   Assignment means you must accept the assigned amount as payment in full and you cannot balance bill the client for any difference between your fee and the assigned amount.

Here’s an excerpt:                                                                                        

“Mandatory AssignmentIn certain situations, a provider, regardless of his/her participating status, must submit an assigned claim to Medicare. The following are instances when an assigned claim is mandatory.

  • The patient is eligible for Medicare and Medicaid.

Submit the claim to Medicare. Medicare will automatically forward payment information directly to Medicaid if the claim has been properly completed.

  • Participating physician/supplier (this would be you if you “enroll” to become a “participating provider”)
  • Services provided by the following non-physician practitioners:” Clinical social workers and clinical psychologists are listed amongst Mandatory Assignment providers (see the link above for the full list and the rest of the information)

Deciding if you should or shouldn’t apply to become a paneled provider on commercial insurance panels, EAPs, and Medicare and Medicaid (if eligible) is an important decision, and possibly one of the biggest decisions you’ll make in private practice.

Something to Consider When Deciding Whether or Not to Become a Network Provider

Many people cannot afford to pay out of pocket upfront, then wait for reimbursement after the hassle of submitting a Superbill or after waiting for the non-paneled therapist to submit claims to the insurance as a courtesy.  When someone is in need of therapy, dealing with Superbills and waiting for possible insurance partial reimbursement can be too much of a strain and a barrier to getting help.

Some people are, however, willing and able to pay upfront. If you decide to go this route- Private Pay only-you’ll be spending more time and possibly more money marketing and advertising.

If you decide to get on a few panels, you can still leave room in your practice for clients on panels you are not on. They can pay you upfront and you can offer them a Superbill for reimbursement. That way you could get your full fee for a few clients rather than the contracted amount you’d otherwise receive if you were on that panel.

A Bit More on Medicare

Being an LCSW* gave me the option of enrolling in Medicare as a participating provider OR Opting Out and charging my full fee to Medicare clients and not billing Medicare (nor could the client receive reimbursement from Medicare).

I chose to enroll.  The reimbursement rate is decent, as far as I am concerned, and better than commercial contracted rates.  Medicare pays in two weeks from the time I submit claims and has generally been a straight-forward process.

The majority of my clients are Medicare age (65 and older) or on Medicare due to disability. There are more people on Medicare in need of therapy than there are therapists able to serve them in some areas. As the boomer population continues to age, the gap between need and available providers may continue to grow.

*check your state for social work or clinical psychologist licensure level requirement to be a Medicare provider – in California for Social Workers it is “LCSW” but in other states the letters are different.

Insurance Resource Review – 5 ***** for this one!

I recently discovered Barbara Griswold, LMFT.  She has a website full of information, offers insurance coaching and webinars, and has published a great book full of insurance information every private practice therapist should have.

Whether you’ve decided on the insurance question or not, I highly recommend you visit Barbara’s website and consider getting her detailed book Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance – And Whether You Should.  

I wish I had this book when I started out five years ago. This 154 page, 19 chapter book is chock-full of information that appears spot on from what I’ve learned these past five years. Here are some of the topics covered:

  • helping you decide if becoming paneled on insurance plans is a good idea for your practice or not
  • how to complete and submit the cms1500 (the insurance claim form)
  • a sample Private Pay Agreement
  • terminology such as copays, coinsurance, managed care, etc
  • Employee Assistance Programs (EAP)
  • getting paid and understanding the Explanation of Benefits (EOB)
  • appealing denials
  • what it’s like to be a network provider
  • and one section I am excited to dig into and put into action called: Getting A Raise (from insurance panels)
  • and more!

The book is nicely organized, concise, and the information is often presented in a Question & Answer format. As a new private practice therapist, this book will give you much of the language and understanding you need to get started.

This book is focused on commercial insurances.

What you won’t find in this book is references to or details about Medicare, Medicaid/Medi-Cal, VA & Military benefits, or Crime Victim programs. As a Medicare and Tricare West (military/veteran) provider, it was a little disappointing not to see at least an overview but, I do understand why these are not included. These programs are a different breed and could be the focus of another book.

Overall, Navigating the Insurance Maze is a wise investment for the new therapist and as well as the one who’s been around a while ;-).

An added bonus about this book: California LMFTs, LCSWs, LPCCs, and LEPs can earn 7 CEUs by purchasing the CEU quiz for the book.

That’s it for now! Lemme know if you’ve found this information helpful and any suggestions for future blog posts you’d like to see.

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For more info about the Private Practice Coaching Services I offer, you can check out my website Navigator News is part of the website and my endeavor to make official that which I have been doing unofficially for a while now – helping others navigate the startup of their private psychotherapy practices.

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