Top 5 Things to Know About Insurance Billing

Insurance isn't so bad but sometimes there are very specific things that don't go over well with most therapists. Insurance thinks differently than we do. Unfortunately, when they're footing the bill it's up to us to learn their language rather than the other way around. 

In my last post I discussed when you should actually say "yes" to insurance. If you've already made that "yes" decision, there's still more you need to know. 

Today I'm breaking things down into the five most important things to know about insurance billing. Have these five things down and you'll be able to answer any clinical question that arises and be prepared ahead of time.

Know the company's definition of medical necessity.

Most company's definitions have similar components. These usually include a diagnosis (and the company may limit diagnoses that can be treated to a certain list), impairment in some area of life in which functioning was previously not impaired, and a clear treatment plan or treatment goals. Know this well enough that you can assess for medical necessity during your initial appointment and always keep this in mind when requesting sessions from insurance.

Be able to describe your client's diagnosis and how it impairs their functioning.

You must be able to described your client's diagnosis and how it impairs their functioning. This is key to explaining why your client's needs should be addressed through therapy rather than other means. Example: Client is on probation at work because he cannot focus and completes tasks late due to symptoms of depression. It is important to spell this out so it is clear the employment problems are related to a mental health issue rather than something else.

Be able to describe how therapy will alleviate your client's symptoms.

Be specific about the areas of life therapy can address. Ask yourself, "why is therapy better for this client than medication, coaching, or even talking to a friend?" You should have a clear answer for every client. Include theoretical techniques and evidence-based practices that work well for that specific diagnosis. 

Have a clear, short-term treatment plan from the outset.

The key to this is the phrase short-term! Insurance companies want to see that you have a clear and understandable treatment plan to focus on this individual's needs. They want to know exactly how long your treatment will take. This requires planning ahead so you know what you'll cover (for the most part) in the coming sessions. Of course, we all know other things may come up but the idea is to plan ahead and be prepared to stay on track as much as possible. Be very proactive!

Know the recommendations or requirements for consulting with other providers.

Some insurance companies would like for you to consult with the client's primary care physician, among others. This can have an obvious impact on treatment. Know what they require, what they recommend and how they'd like you to document that consultation. Ask about the frequency and expectations and make sure to discuss this with your client in an objective way once you're clear on your role. Side note: And yes, still get written authorization from your client!

I created these tips to be simple and easy to follow. If you'd like a pretty downloadable version, feel free to click here and save.

I know that many of you still have more specific questions. No worries! While I may be an insurance mole, I'm not a billing expert. But I know another therapist who is! Barbara Griswold has an excellent book available on this topic. If you're a counselor and plan to contract with insurance, this is a must-have. Click below to check it out:

And, as usual, feel free to post your questions or comment below! 

One caveat: Every provider has a different contract so an answer that may apply to one person may not apply to you. Be careful when interacting with others and assuming as such since you may unknowingly mislead someone.

Happy writing (and happy billing)!