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In Network. Outta Network. Upside Down

If you're a small(ish) practice, you may have opted to avoid the........"fun" of taking insurance. Sticking to self-pay makes billing a breeze. Your services cost x and your clients pay x.....if you offer sliding-scale, then your services cost x and your clients pay x-y. Easy peasy.


There is a lot to be said for not getting involved with insurance, especially if your services are more in depth that what insurance "deems necessary" and you don't feel like getting nickeled and dimed to death when it comes to providing the level care you prefer to give to your clients.


On the other hand, if you only offer a few services and your clients struggle to pay your self-pay rate out of pocket, you might be considering getting credentialed with one (or several) insurance payers. Being able to offer your same high quality services AND get paid (almost) what you're worth??!!! Yes, please! Folks can pay their $25 copay and you'll get additional funds from the insurance company.


That being said, all insurance is not created equal, and there are plans that may be more of a value to you/your clients than others. If you've never accepted insurance before, survey your existing clients to see which payer(s) would give you the most bang for your buck. You may also want to discuss reimbursement rates with your fellow providers to see which ones they love and those they wish they'd never signed up with.


Benefit Verifications...An Exercise In Patience

Ok. So now that you're in-network with the client's insurance provider, you need to determine what your client's anticipated out of pocket costs for your service(s) will be. I've created a simple (and free) Insurance Verification Form so you know the bare minimum information needed to verify benefits.


The least tech savvy (and generally most time consuming) method for checking benefits is to call the Provider Services number on the back of your clients' insurance card. If you go this route, my advice is to collect multiple clients with the same payer so you can call once and knock out several verifications with one call.


My preferred method is to use the payer's online portal and look up benefits online. This way, you only need to call if the information provided online is unclear, or you learn that claims for your specific services are processed by a third-party. Example: Magellan processes mental health claims for *some* BCBS plans, but you have to specifically be credentialed with Magellan to be considered in-network. So even if you're in-network with BCBS, your claims will be out of network because they're administered by Magellan.


If this all sounds confusing and stressful, that's because it's confusing and stressful. I've spent a LOT of time on the phone with helpful (and some not so helpful) folks at the various insurance companies out there and, more often than is comforting, they seem to be just as confused about coverage as you/me/clients/everyone else. I'm not trying to drum up business, but if you have the opportunity to bring an insurance verification specialist to your team...DO IT. And if you already have someone verifying benefits for you...give them a raise and a (consensual) hug. They probably need it after being on hold for a billion hours.


Pre-Authorizations & Referrals

Another charming aspect of insurance is knowing when/what/how to get pre-authorizations and referrals. First, know that they are two sides to one coin: getting someone else to agree with you/the client that a service needs to be performed. Some plans require clients to get referrals for EVERYTHING. Therapy? REFERRAL!!! Chiropractic adjustment? REFERRAL!!!!!! Psychological Evaluation? Pre-Authorization required....but then you submit the pre-auth and get a letter from insurance telling you an auth isn't required...


All This To Say...

Don't avoid taking insurance just because it's confusing and can be time consuming and adds another layer of *paperwork* to your life. Being in network with the insurance your primary client base uses can be what ensured they receive a continued level of quality care.

Give me a call, shoot me a text or email if you aren't sure if tackling insurance is the right move for your practice, or if you've been taking insurance for a while and are running into billing, claims, or other issues.

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