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practice need to make is whether to accept insurance reimbursement. There are compelling reasons for and against, but this issue propelled me into private practice. As licensed clinicians, several colleagues and I left our former employer when the administration decided to
stop accepting commercial insurance. This comprised most of our client base, and we took our insurance clients with us.
Despite being paneled for years through my agency, I had to learn about navigating insurance claims in private practice. In many ways, it was like starting over. Here are ten tips for navigating the insurance process for clinicians beginning a private practice, wishing to add insurance reimbursement to practice, or aspiring to improve their current experience with insurance.
1. Stay the Course Getting credentialed and contracted with insurance companies can be a lengthy process, taking from two to six months, depending on the company. Previously having been paneled helps with some companies, but not all. When transitioning from agency work to private practice, it is prudent to expect a three-month period for paneling to occur. Every insurance company has separate credentialing and contracting processes, each run by different departments. Because this process is protracted and tedious, some therapists hire someone to do credentialing and contracting for them, especially if they still work for an agency while trying to create a private practice.
2. Prepare the Application To initiate the credentialing and contracting processes, clinicians will need is a unique ten-digit number assigned to providers under the Health Insurance Portability and Accountability Act (HIPAA). CAQH works with insurance companies to store provider information in one place, such as practice address and malpractice information.
need to obtain numbers and access codes from their agency’s human resources representative, then will need to update these for use in private
proview.caqh.org, 1-888-599-1771), and can apply for an NPI on the National Plan and Provider Enumeration System website (
www.https://
nppes.cms.hhs.gov/#/).
3. Research, Compare, and Apply Insurance plans and policies differ, including the rates they offer and the paperwork required to contract with them. Therapists should investigate which insurance plans are offered most in their geographic area, and check with other area providers about their experiences and recommendations. When I took my caseload with me, I examined which insurance plans my
next three applications. These six companies provided enough referrals for my practice. For the few insurance companies that clients rarely used, I obtained single-case agreements.
Therapists need to research the insurance rates in the area. Agency therapists are paid a contracted fee per client, and many do not know the insurance company reimbursement rate. However, this information is invaluable. As an in-network private practitioner, I negotiated a better rate with one company that initially offered a much lower rate than the others because I knew the local reimbursement rates.
plans offer. Therapists can request OoN coverage during the in-network OoN contracts with a company could help therapists secure in-network agreements with that company.
4. Note Provider Representatives’ Names In this electronic age,
it may seem outdated to learn the provider
representative’s name for each insurance company, but s/he can be a valuable resource when credentialing and practice questions arise. When application hiccups surface, it helps to ask for the representative directly to check into things and to facilitate the process.
I had an application stall in the process. The provider representative for that company responded to my inquiries in a timely fashion and got my application back on track, checking with me throughout the process. Once
5. Emphasize Your Specialties During the application process, therapists may be told that companies have enough providers in their geographic area. In my experience, most of these other practitioners counsel adults. For two major insurance companies locate therapists who accept insurance and specialize in working with children and families through play therapy. In emphasizing my specialties, I was admitted into both networks. Describing specialties to insurance representatives also may facilitate future referrals from the company.
Insurance companies often appreciate referring to providers who offer atypical appointment times, as well: evening or weekend hours that better accommodate families’ school and/or work schedules. A part- time therapist in our group provides Sunday afternoon sessions. No other therapists in our area offered those appointment times. Offering atypical needs, and get paneled as private practitioners.
6. Learn the Billing Codes Therapists must understand the use of current procedural terminology (CPT) codes, which is the language for billing services under insurance. Health insurance companies decide which CPT codes they will reimburse, so clinicians should obtain a list of all reimbursement-eligible CPT codes
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